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LECTURES 



DIAGNOSIS AND TREATMENT 



FUNCTIONAL NERVOUS AFFECTIONS. 



BY 



C. E. BROWN-SEQUAKD, M.D., F.R.S., 

FELLOW OP THE EOYAL COLLEGE OP PHYSICIANS OP LONDON, MEMBER OP THE -NATIONAL 
ACADEMY OF SCIENCES (U.S.) ETC. 



PART I. 

PHYSIOLOGICAL PATHOLOGY AND GENERAL THERAPEUTICS 
OF FUNCTIONAL NERVOUS AFFECTIONS. 



PHILADELPHIA: 
J. B. LIPPINCOTT AND COMPANY. 

1868. 






> 



LECTURES 



ON THE 



DIAGNOSIS AND TREATMENT 



FUNCTIONAL NERVOUS AFFECTIONS. 



BY 



/. 



C. E. BKOWN-SEQUARD, M.D., F.E.S., 



FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON, MEMBER OF THE NATIONAL 
ACADEMY OF SCIENCES (U.S.), ETC. 




10 



Z 5 

PHILADELPHIA: 
J. B. LIPPINCOTT AND COMPANY. 

1868. 



a^ 



J 



Entered according to Act of Congress, in the year 1868, by 

J. B. Lippincott & Co., 

In the Clerk's Office of the District Court of the United States for the Eastern 
District of Pennsylvania. 



CAMBRIDGE : 
PRESS OF JOHN WILSON AND SON. 



PREFACE. 



The recent immense advances of our knowledge as regards the 
physiology of the nervous system and the action of remedies, 
have thrown a great deal of light on the symptoms and treat- 
ment of functional nervous affections. Medical practitioners, 
becoming daily more and more learned in physiology, are now 
constantly applying the new physiological notions to the prac- 
tice of their art, and considerable progress in the science and 
practice of medicine, especially as regards organic and func- 
tional nervous affections, has resulted therefrom. 1 

The vast field, opened sixteen years ago by the two funda- 
mental experiments on the sympathetic nerve, which show the 
effects of its paralysis and those of its irritation on blood ves- 
sels, and, consequently, on circulation, animal heat, and nutri- 
tion, has already been considerably fertilized. Since the time 
when I first described, in a course of Lectures at the Royal 
College of Surgeons, of England, the morbid phenomena re- 
sulting from a paralysis or an irritation of the vaso-motor nerves, 
the study of these important phenomena has been pushed for- 
ward with great energy and success, by a large number of 

1 A good illustration of th8 importance of the application of physiology to the 
practice of medicine has been given by Dr. Howard F. Daaiox, jn his recent very 
interesting and ingenious work on "The Neuroses of the Skin: their Pathology and 
Treatment." 



4 PREFACE. 

physiologists and medical practitioners ; and if there is a fault 
now as regards the influence of vaso-motor nerves, it is certainly 
not that too little attention is paid to it, but rather that too 
many morbid phenomena are ranged under the badly defined 
title of vaso-motor neuroses. Indeed, frequent mistakes are 
made by many physicians, who attribute to effects of paralysis 
or irritation of the vaso-motor nerves symptoms which are 
due to similar alterations of a totally different set of nerves, 
constituting what should be called nutritive or secretory 
neuroses. 

I intend, in these lectures, to give a practical history of the 
diagnosis and treatment of neuroses, founded upon clinical 
observation, enlightened by physiology and experimental pa- 
thology and therapeutics. The lectures will be grouped into 
three parts, each of which will form a complete work by itself; 
the first part relating to general remarks on the causes, diag- 
nosis, and treatment of neuroses ; the second, to the history of 
each of the pure functional nervous affections ; the third, to 
vaso-motor and nutritive neuroses, and to functional nervous 
affections due to syphilis or to rheumatism, to diseases of the 
kidneys, the liver, &c, or to alterations of the blood, &c. 

The first part, which now appears, will be soon followed by 
the two others. 

C. E. BROWN-SEQUARD. 

Cambridge, Mass., May, 1868. 



PAET I. 

PHYSIOLOGICAL PATHOLOGY AND GENERAL THERAPEU- 
TICS OF FUNCTIONAL NERVOUS AFFECTIONS. 



CONTENTS. 



LECTUKE I. 

ON THE CAUSES AND DIAGNOSIS OF FUNCTIONAL NERVOUS 
AFFECTIONS. 

Existence of special conductors for the various kinds of sensations, and for 
voluntary and involuntary movements of muscles and blood-vessels, &c. 
— Dilatation of blood-vessels due to nerves of nutrition and secretion. — 
Variety of effects produced by an irritation of the same centripetal 
nerve, illustrated by the morbid effects caused by a neuralgia, and by 
those of an excitation of the skin of the neck by cold air, and of the 
tickling of the soles^of the feet. — Causes of increase of excitability in 
the various parts of the nervous system. — Extent of the normal and 
morbid influences of the nervous system on nutrition and secretion. — 
Three fundamental causes of disease in the various organs. — Diagnosis 
of functional and organic nervous affections 



LECTURE II. 

ON MEANS OF SUPPRESSION OR DIMINUTION OF THE CAUSES OF 
FUNCTIONAL NERVOUS AFFECTIONS. 

Local applications of narcotics, of ice, and of the actual cautery. — Section 
of nerves. — Ablation of the clitoris. — Trephining of the cranium. — 
Ligature of the carotid artery. — Tracheotomy. — Cauterization of the 
urethra. — Various means of diminishing the reflex excitability of the 
nervous centres. — Means of producing sleep. — Mode of action of iron 
in improving nutrition. — Powerful influence of exercise. — Elimination 
of poisons _ 26 



LECTURE III. 

ON MORAL, PHYSICAL, AND VARIOUS OTHER MODES OF TREATMENT 
OF FUNCTIONAL NERVOUS AFFECTIONS. 

Importance of a serious mental occupation. — Means of increasing and of 
decreasing the quantity of blood in the limbs, the trunk, or the head. — 
Irritation of nerves of the skin and other peripheric parts, as a means of 
curing a morbid state of the nervous centres. — Therapeutic use of cold 
and heat. — Cauterization of fauces and larynx. — Baths. — Pressure on 
the carotid artery. — Special treatment of periodical affections. — Special 
use of ana3sthetics 41 



CONTENTS. 



LECTURE IV. 

GENERAL VIEWS ON THE MODES OF ACTION AND ADMINISTRA- 
TION, THE ANTAGONISM, &c, OF REMEDIES USED AGAINST 
FUNCTIONAL NERVOUS AFFECTIONS. 

Difficulties in finding out the ultimate mode of action of remedies. — Thera- 
peutic analogies and differences of remedies. — Subcutaneous injections 
in cases of neuralgia and other neuroses. — Influence of chloroform in 
increasing the rapidity of cutaneous absorption. — Usefulness of several 
neglected methods of administration of remedies. — Advantages of 
alkaloids over extracts and other compounds. — Antagonism between 
belladonna, stramonium, hyoscyamus, quinine, on the one hand, and 
opium on the other. — Necessity of large doses of remedies against 
neuroses. — Usefulness of association of certain remedies. — Rules of 
administration of the bromides of potassium and of ammonium in 
epilepsy. — Mutual influence of certain narcotics upon each other . . 63 



DIAGNOSIS AND TREATMENT 



FUNCTIONAL NERVOUS AFFECTIONS, 



LECTURE L 

ON THE CAUSES AND DIAGNOSIS OF FUNCTIONAL NERVOUS 

AFFECTIONS. 

Existence of special conductors for the various kinds of sensations, and for 
voluntary and involuntary movements of muscles and blood-vessels, &c. 
— Dilatation of blood-vessels due to nerves of nutrition and secretion. — 
Variety of effects produced by an irritaiion of the same centripetal nerve, 
illustrated by the morbid effects caused by a neuralgia, and by those of 
an excitation of the skin of the neck by cold air, and of the tickling of the 
soles of the feet. — Causes of increase of excitability in the various parts 
of the nervous system. —Extent of the normal and morbid influences of 
the nervous system on nutrition and secretion. — Three fundamental 
causes of disease in the various organs. — Diagnosis of functional and 
organic nervous affections. 

Gentlemen, — In this and in the next three lectures 
I intend to call your attention to the most important 
advances in our knowledge of the causes, the diagnosis, 
and particularly the treatment, of functional nervous 
affections, leaving for the succeeding lectures the special 
study of each of these affections. 



10 DIAGNOSIS AND TREATMENT OF 

I. REMARKS ON THE KINDS OF NERVE-FTBRES, THE IRRITA- 
TION OF WHICH MAY PRODUCE NERVOUS AFFECTIONS. 

One of the most interesting of the recent advances in 
Physiology and Pathology consists in the demonstration, 
that the nervous conductors serving to the following 
functions — the transmission of the various kinds of sen- 
sitive impressions, the reflex phenomena, the conveyance 
of nervous force to muscles or to blood-vessels, &c. — are 
absolutely distinct, one from the others, as regards their 
special function. There is no contradiction between 
this assertion and the important facts discovered by 
Messrs. Vulpian and Philipeaux, 1 proving that nerve- 
fibres are mere conductors, able to transmit nervous force 
either towards or from the nervous centres ; and that the 
same nerve-fibre may serve to motion or to sensation, 
when transplanted from one nerve into another. These 
facts are completely reconciled with the above assertion 
by the so well-established theory, that the function of 
nerve-fibres depends, not on peculiar or specific proper- 
ties of their own, but on the properties and functions of 
the organs into which they are distributed, and the parts 
of the nervous centres from which they spring. 

Not counting the nerve-fibres of the brain, many of 
which have functions altogether different from those of 
other parts of the nervous system, I have ascertained, 
that, besides the four distinct kinds of nerve-fibres of the 
higher senses, there are at least eleven distinct kinds of 

1 See the admirable paper of Vulpian and Philipeaux in "Journal de la Pliy 
siologie de l'Homme/' &c., vol. vi. 1803-65, pp. 421-65 and 474-510. 



FUNCTIONAL NERVOUS AFFECTIONS. 11 

nerve-fibres in the spinal cord, and in the cranial, spinal, 
and sympathetic nerves. 

The following table shows what are the distinct func- 
tions of these eleven kinds of nerve-fibres. 1 They are 
the — 

1. Conductors of impressions of touch. 

2. Conductors of impressions of tickling. 

3. Conductors of impressions of pain. 

4. Conductors of impressions of temperature. 

5. Conductors of impressions of muscular contraction (muscu- 

lar sense). 

6. Incito-motor conductors. 

7. Incito-nutritive and secretory conductors. 

8. Voluntary motor conductors. 

9. Involuntary motor conductors. 

10. Yaso-motor conductors. 

11. Nutritive and secretory conductors. 

I hardly need to say, that the number of functionally 
distinct nerve-fibres is probably much greater than is 
shown by this table ; but the demonstration of the exist- 
ence of other special kinds of nerve-fibres (such as those 
serving to the sensations of hunger, of thirst, of pres- 
sure, or to voluptuous sensations, &c.) is not yet suffi- 
ciently decisive. 

I I hare shown that the nerve-fibres serving to sensations of touch, of tickling, 
of pain, and of temperature, are not only completely distinct one from the others, 
but that, after having entered the spinal cord as parts of the posterior roots of the 
spinal nerves, and after a complete decussation between the fibres of the two sides 
of the body in that nervous centre, they form in it distinct groups or columns of 
conductors ; so that an alteration, limited to a small part of the spinal cord, may 
strike either the column for touch, or that for tickling, or one of the other two 
kinds of conductors of sensitive impressions. I have shown, also, that conductors 
for the muscular sense differ from the conductors just spoken of in this respect, 
that they do not decussate in the spinal cord, but that they form also a distinct 
column in each lateral half of that organ. (See "Journal de la Physiologie de 
l'Homme," &c, No. 24, 1865, vol. vi. pp. 610-13 and 645.) 



12 DIAGNOSIS 'AND TREATMENT OF 

Almost all the symptoms of functional (and I might 
say, also, of organic) nervous affections take place 
through one or other of three modes of alteration of the 
properties and functions of the fifteen kinds of conduct- 
ors above named. These three modes consist in — 

1. A diminution or loss of power. 

2. An increase of power. 

3. A perverted or morbid state, producing a great variety of 

phenomena. 

In the nine kinds of conductors serving to the trans- 
mission of sensitive impressions, the first of these three 
modes of alteration constitutes anaesthesia ; the second, 
hyperesthesia ; and the third is the cause of morbid sen- 
sations (including the so-called referred sensations). 

Without entering into details about the kinds of 
nerve-fibres which I call incito-motor, incito-nutritive, or 
secretory, or about those which I simply name nutritive 
or secretory, I will say a few words concerning their 
physiological and pathological history. 

1. Incito-motor nerves. — These are the well-known 
excito-motor nerves of Marshall Hall. A great many 
facts prove that they are absolutely distinct from the 
sensitive nerves. All the reflex movements of the mus- 
cles of organic or animal life (including the excretory 
ducts of glands, the blood-vessels, &c.) originate through 
an irritation transmitted by these incito-motor nerves to 
the nervous centres. 

2. Nutritive and secretory nerves, and incito -nutritive 
and secretory nerves. — Shorter names should perhaps 
be given to these nerves : but, so long as their real mode 



FUNCTIONAL NEKVOUS AFFECTIONS. 13 

of action remains somewhat doubtful, I think it is better 
to call them by names which only state what we posi- 
tively know of them ; i.e., that they ara agents of modi- 
fication of secretion and nutrition. The secretory and 
nutritive nerves are in many respects the antagonists of 
the vaso-motor nerves. While these last nerves, when 
put in action, produce a contraction of blood-vessels, and 
all the phenomena which I have shown to ensue from 
that contraction (i.e. chiefly a diminution of the quan- 
tity of blood, in consequence of which the various vital 
properties, the secretions and animal heat, diminish 
also), 1 the nutritive and secretory nerves, on the con- 
trary, when put in action, occasion a dilatation of blood- 
vessels, and all the phenomena that ensue from it, as 
shown first by experiments of Czermak and of CI. Ber- 
nard. 

I proposed long ago (in my lectures at the College 
of Surgeons, of London, in 1858) 2 an explanation of 
the action of these nerves, which the discovery of sev- 
eral new facts year after year has rendered more and 
more probable. 3 This explanation is, — first, that the 
secretory and nutritive nerve-fibres act upon the tissues, 
so as to increase the chemical interchange between them 
and the blood, and that, in consequence of this increase 

1 See my " Course of Lectures on the Physiology and Pathology of the Cen- 
tral Nervous System," p. 142. 

2 See Course of Lectures, ahove quoted, p. 149. 

3 The admirable researches made by Ludwig on the salivary secretion (in 
Henle- and Pfeuffer's "Zeitschrift fur Eat. Med.," 1851, vol. i. p. 260), have 
shown, that, even when the circulation of blood is interrupted, nervous force can 
be transformed into chemical force in the salivary glands, as an irritation of the 
nerves of these glands will, for a time after the stoppage of circulation, produce a 
secretion of saliva. 



14 DIAGNOSIS AND TREATMENT OF 

of chemical activity, much, more arterial blood is attracted 
by the tissues ; and, secondly, that this greater afflux of 
arterial blood causes the dilatation of blood-vessels ob- 
served by the various experimenters who have studied 
this subject. In health, as well as in many morbid 
states, it is chiefly by a reflex action that this kind of 
nerve-fibres produce their peculiar effects on nutrition 
or secretion. The redness, the congestion, of parts at- 
tacked with neuralgia, or the neighboring parts ; the 
secretion of tears when the eye is irritated, or the skin 
of the face pinched ; the secretion of mucus from the 
nasal, laryngeal, tracheal, or bronchial mucous mem- 
branes ; or the diarrhoea produced by cold ; and also an 
immense number of other instances in which there is a 
congestion or a secretion as a result of an irritation of 
cutaneous or other nerve-fibres, — are all effects of the 
peculiar influence exerted by secretory and nutritive 
nerve-fibres on glands and other tissues. 

These nutritive and secretory nerve-fibres are, as I 
have tried to prove elsewhere, the agents of production 
of inflammation, suppuration, and ulceration, by a reflex 
action. They are the channels of production of menin- 
gitis, of encephalitis, or myelitis, when those inflamma- 
tions are due to cold, to a burn, or to a visceral affection. 
They also have a great share in the production of many 
functional nervous affections, and particularly tetanus. 
Besides, through the agency of these nerves, much may 
be done for the treatment of nervous affections, as I will 
show hereafter. 

The incito-secretory and nutritive nerve-fibres are the 



FUNCTIONAL NERVOUS AFFECTIONS. 15 

incident or centripetal nerve-fibres which, by a reflex 
influence, act upon the centrifugal secretory and nutri- 
tive nerve-fibres. Their distinct existence is not fully 
demonstrated, but many facts render it extremely proba- 
ble. 1 

II. CAUSES OF FUNCTIONAL NERVOUS AFFECTIONS. 

The causes of functional nervous affections can be 
classified as follows : — 

1. An irritation (by worms, by teething or decayed teeth, by 
cold, by a burn), a wound, an inflammation, a neuralgia, 
&c, of centripetal nerve-fibres (the incito-motor, the incito- 
nutritive, and some others). 

£. An alteration in the quantity or the quality of blood. 

3. The co-existence of both the preceding kinds of causes, as in 
cases of typhus fever, of variola, of diphtheria, of uraemia 
from disease of the kidneys, of cholesteraemia, &c. 

I will not insist here on the mode of action of these 
causes; but there are a few general remarks which will 
be in their proper place in this introductory lecture. 
There are two general rules which particularly deserve 
attention : — 

1. The same peripheric cause of irritation, acting on 
the same centripetal nerve, may produce the greatest 
variety of effects, including every functional nervous affec- 
tion or disorder. This is well illustrated by the various 

1 The independent existence of an excito-secretory system of nerves has been 
assumed, but not proved, by Dr. Henry F. Campbell, of Georgia, and by Marshall 
Hall. (See Campbell's prize essay in " Transactions of the American Medical 
Association," vol. x. 1857, p. 465, and his claim to priority in " The Lancet," 
London, 1857, vol. i. p. 462 ; and Marshall Hall's paper on the Excito-secretory 
Sub-system of Nerves, in " The Lancet," London, 1857, vol. i. pp. 2 and 464.) 



16 DIAGNOSIS AND TREATMENT OP 

following effects on the eye 'of a neuralgia of the infra- 
or supra-orbitalis nerves. There are such cases show- 
ing — 

1. Spasm of the sphincter of the pupil. 

&. Mydriasis. 

3. Spasm of the orbicularis palpebrae. 

4. Paralysis of the orbicularis. 

5. Paralysis or spasm of one or several of the muscles of the 

ocular globe. 

6. Photophobia. 

7. Amblyopia or amaurosis. 

8. Congestion or inflammation of the conjunctiva, or of other 

parts of the eye. 

9. Diminution or increase of the secretions of the lachrymal 

and other glands. 

10. Cataract. 

11. Glaucoma. 1 

Many other examples, less striking, however, might 
be adduced. I will only mention what we know as re- 
gards the effects of cold air on persons coming out of 
a theatre. One may be attacked with a sore throat, a 
second with ophthalmia, a third with enteritis, a fourth 
with nephritis, and many others with any other vis- 
ceral inflammation. Again, one may be attacked with 
facial paralysis, and others with almost every other 
partial paralysis, or with chorea, with contracture, with 
an inflammation of some parts of the nervous centres or 
of their meninges. It is true that it is not always the 

1 See the excellent paper of Notta on Neuralgia, in "Archives de Mcde- 
cine, Juillet, Septembre, et Novembre, 1854 ; " ray work on the " Central Ner- 
vous System," p. 157; and the very original dissertation of Rondeau, "Des 
Affections Oculaires Reflexes," Paris, 1866. 



FUNCTIONAL NERVOUS AFFECTIONS. 17 

same part of the skin which is submitted to a sudden 
lowering of its temperature, and that the differences 
in the nature and in the seat of the reflected morbid 
effects may sometimes be due to differences in parts 
of the skin exposed to a draft of air ; but in most- 
cases, however, notwithstanding the great variety of 
morbid effects, it is the same part, i.e. the front part 
of the neck and chest, which is irritated .by the cold 
air. 

It is extremely probable, that the considerable variety 
of morbid phenomena, which follow an irritation of 
centripetal nerve-fibres, depends almost entirely on dif- 
ferences of excitability of the various parts of the ner- 
vous centres in different individuals. I have examined 
carefully, on a large number of men, the effects of tick- 
ling the sole of the foot, and found that these effects 
differed considerably in different individuals. In some, 
laughter predominated ; in others, involuntary scream- 
ing, or shedding of tears, or jerks either only in the 
irritated limb, or in both lower limbs, or, in a few in- 
stances, in the two limbs of one side, or in the four 
limbs, or a general trembling, or a spasm of the dia- 
phragm, or an almost tetanic rigidity of the irritated 
limb. I hardly need to add, that, in some individuals, 
there was no marked effect produced by the tickling, 
especially when, being prepared for the irritation, they 
made an effort to prevent its action ; a fact which, 
with many others of similar purport, shows that our 
will has sometimes the power of preventing the pro- 
duction of reflex phenomena. 



18 DIAGNOSIS AND TREATMENT OF 

2. The degree of excitability of the various parts of 
the nervous system not only differs extremely in differ- 
ent persons , but it may increase or decrease considerably 
in the same person under the influence of many causes. 
This proposition is of so great an importance in the 
diagnosis and treatment of nervous affections, that it 
is only by the light it throws on many otherwise very 
obscure cases that we are enabled to recognize their 
nature, and to apply to them the proper treatment. 
Many parts of the nervous system that are completely, 
or almost completely, inexcitable in a healthy condition, 
become excitable, and sometimes in a wonderfully high 
degree, under the influence of several morbid causes. 
Among these parts, I will point out the grey matter 
of the spinal cord, and the nerves of the tendons, apo- 
neuroses, dura-mater, periosteum, bowels, bladder, kid- 
neys, and some other viscera. Many causes, very different 
one from the others, may increase the excitability of 
the various parts of the nervous system. I will only 
mention here the principal of these causes : — 

1. I have found that muscles, nerves, and the spinal 
cord, become more excitable after having been laid 
bare, and especially when the air in contact with them 
has been rendered richer in oxygen than the ordinary 
atmospheric air. 1 

2. A congestion, and, still more, an inflammation, will 
produce a great excitability of nervous tissues every- 
where, but nowhere so markedly as in the grey matter, 

1 See "Proceedings of the Royal Society," vol. viii. 1857, p. 598; and "Jour- 
nal de la Physiol, de l'Hoinine," &c, vol. i. 1858, p. 617. 



FUNCTIONAL NERVOUS AFFECTIONS. 19 

and some parts of the white columns, of the spinal 
cord, which, in consequence of this change, will become 
able to produce referred sensations of pain, of cold or 
heat, of tickling, &c, and also the phenomena that 
result from an irritation of motor, vaso-motor, and 
nutritive nerves. 

3. An afflux of blood, such as occurs merely by gravi- 
tation, or after a section or a paralysis of the sympa- 
thetic nerve, or a lesion of the spinal cord, the medulla 
oblongata, or the base of the brain, will also increase 
the excitability of peripheric nerves in the parts where 
this afflux takes place. 

4. Certain remedies or poisons (strychnine particu- 
larly) will increase the reflex excitability of the spinal 
cord to a wonderful degree ; while others, such as atro- 
pine, will diminish it considerably. 

5. Certain diseases, such as tetanus and hydrophobia, 
will increase extremely the reflex excitability of some 
parts of the cerebro-spinal axis. 

6. A great loss of blood, anaemia, chlorosis, will also 
increase considerably the reflex excitability of the ner- 
vous centres. 

The increase of reflex excitability in cases of extreme 
debility, as in old age, or after a loss of blood, or other 
causes of insufficient nutrition, would be very difficult 
to understand, if we did not know that the reflex ex- 
citability of the spinal cord can be increased under 
the influence of certain substances (strychnine princi- 
pally), when no blood at all remains in the blood-vessels 
of that nervous centre, as proved beyond the possibility of 



20 DIAGNOSIS AND TREATMENT OF 

doubt by Messrs. Martin-Magron and Buisson. 1 The ex- 
citability of sensitive nerves may also be increased when 
the quantity of blood is much diminished, as we often 
observe in ringers that have been exposed to cold air or 
cold water. It seems, from a review of all the facts I 
know bearing on this point, that certain substances 
contained in blood altered in quantity or quality will 
act on the excitabilitv of nerve-fibres in the nervous 
centres, or in the nervous trunks and branches, so as 
either to increase it, as is done by strychnine (on the 
grey matter) and oxygen (everywhere), or to decrease 
it, as is done by carbonic acid, atropine, &c. 

To conclude what I wish now to say on the excita- 
bility of nerves, I will only mention, — 1st, That I have 
ascertained that the excitability of the same nerve varies 
in different parts of its length, and to such a degree, 
that, in some parts, the excitability seems nil or is very 
slight, while in other parts it is considerable ; 2d, That 
I have shown by positive experiments, that the excita- 
bility of muscles, of nerves, and of the spinal cord, may 
be very much increased, while the force developed by 
the action of those parts is very small. For instance, 
atrophied muscles, unable to contract with half the 
force shown by healthy muscles, will, however, con- 
tract under the influence of an excitation that will 
produce no effect on healthy muscles. 

I will say only a few more words on the causes of 
functional nervous affections. The important discus- 

1 See "Journal de la Physiologie," &c., vol. ii. 1859, p. 484, and vol. iii. 1860, 
p. 130. 



FUNCTIONAL NERVOUS AFFECTIONS. 21 

sions between Virchow, Spiess, and others, on the share 
of the nervous system in the causation of the various 
morbid alterations of tissues and organs, have been 
very useful in bringing forward many interesting facts ; 
but the exclusiveness of the two opposite schools, at 
the head of which are the eminent men I have just 
named, has thrown a great deal of obscurity on ques- 
tions which, considered with less partiality, might have 
been solved easily. It is certainly true, as maintained 
by Virchow, 1 that nutrition and secretion, normal and 
abnormal, can be carried on without the intervention 
of the nervous system ; but this does not at all prove, 
that that system cannot interfere, for good or for evil, 
in nutrition and secretion in the various tissues and 
organs. For instance, there is no doubt whatever, that 
an inflammation, followed or not by suppuration and 
ulceration, can take place without any intervention of 
the nervous system ; but there is no doubt also, that the 
same morbid processes, not only can be, but very 
frequently are, produced by a nervous agency. Indeed, 
facts are extremely numerous which establish clearly, — 
on the one hand, that normal nutrition and secretion 
do not depend essentially on any kind of interference by 
the nervous system, and that all morbid changes in these 
fundamental organic functions can take place without 
any nervous influence ; and, on the other hand, that 
the nervous system may, and even almost constantly 
does, influence nutrition and secretion, and that it very 

1 See Dr. Chance's excellent translation of Virchow's " Cellular Pathology/' 
Lect. XIV. London, 1860. 



22 DIAGNOSIS AND TREATMENT OF 

frequently produces, or helps to produce, a great variety 
of morbid alterations of these two functions. 

Not only can an excitation of the same nerve pro- 
duce effects in the different parts of the nervous centres, 
in one or another of the viscera, or in distant nerves or 
muscles or bones, &c. ; but it can also produce, in the 
same part of the nervous centres, in the same viscus, 
in the same muscle, &c, different kinds of alteration. 
Why is there such a variety of alterations produced 
in one and the same part by an excitation which varies 
only in intensity'? To answer this question, I must go 
beyond the limits of the subject-matter of these lectures, 
and cast a glance on the mode of production of morbid 
affections of the various tissues and organs. Physiology, 
morbid anatomy, and clinical observation, clearly point 
out, that all nervous affections (organic and functional), 
as well as affections of any other part of the body, 
owe their production to three different fundamental 
causes : — 

1. A special inherent tendency (inherited or not) of the ele- 

mentary parts of the tissues to become altered in one or 
in another way. 

2. The production or introduction in the blood of those mate-' 

rials which are necessary for the formation of morbid 
growths, or able, like poisons, to cause alterations of 
nutrition or secretion. 

3. An influence of an excitation from outside, acting with or 

without the intervention of the nervous system, or a 
purely nervous influence starting from a peripheric or 
a central part of the nervous system. 

If we keep in mind the truth that these three causes 



FUNCTIONAL NERVOUS AFFECTIONS. 23 

may exist together and in various degrees, we can easily 
understand how the same excitation of the same nerve 
may produce in the same distant part different kinds 
of alteration of nutrition. It is so that an irritation 
from a wounded nerve, as I have proved elsewhere, 1 
will produce either tetanus or chorea or catalepsy or 
epilepsy or delirium, &c, and, by a reflex action on a 
peripheric part, muscular wasting or trembling, a con- 
tracture, a neuralgia, &c. 

III. GENERAL REMARKS ON THE DIAGNOSIS OF FUNCTIONAL 
NERVOUS AFFECTIONS COMPARED WITH THAT OF ORGANIC 
NERVOUS DISEASES. 

I now pass to the diagnosis of functional nervous 
affections, on which subject I will only point out in 
parallel columns the principal distinctive features of 
these affections, compared with those of organic nervous 
diseases. 

Characters of Functional Nervous Characters of Organic Nervous 

Affections. Diseases. 

1. The principal causes are an 1. One of the principal causes is a 
alteration of the blood, and an irrita- special tendency (inherited or not) to 
tion of a part of an incident or centrip- inflammation, to alterations of blood- 
etal nerve, by a neuralgia, by worms, vessels, or to the formation of morbid 
by teething or decayed teeth, by a growths, etc. 

wound, a burn, &c. 

2. Great variability in the intensity 2. Persistence of the principal 
of the symptoms, and regular or irreg- symptoms, with slow variations in 
ular recurrence of attacks, with inter- their intensity. 

vals of almost perfect health between 
these attacks. 

1 I have given a complete demonstration of the correctness of the above as- 
sertion in the article on Diseases of Nerves, in Holmes's " System of Surgery." 
1862, vol. iii. p. 876, et seq. 



24 



DIAGNOSIS AND TREATMENT OF 



3. A sudden or rapid cure or im- 
provement is not rare. 

4. Certain symptoms — such as a 
sensation of pricking, of formication, 
of burning heat, of icy cold, and other 
symptoms of irritation of conductors 
of sensitive impressions, and also al- 
terations of nutrition and secretion of 
the skin and of mucous membranes 
and glands (bladder, kidneys, &c.) — 
are extremely rare, except in a few of 
these affections (neuralgia, affections 
due to alterations of blood, &c.) 

5. The temperature of the affected 
parts is generally low. 

6. The sphincters of the bladder and 
rectum are usually normal. 

7. An aura, felt or untelt, very fre- 
quently exists in some forms or periods 
of epilepsy, hysteria, catalepsy, hydro- 
phobia, tetanus, &c. 

8. To remove the cause is a funda- 
mental part of the treatment. 



3. A sudden or almost sudden cure 
is impossible, and a rapid improve- 
ment is exceedingly rare. 

4. Most of the symptoms due to 
the irritation of conductors of sensitive 
impressions and of nutritive and secre- 
tory nerve-fibres, are constant or ex- 
tremely frequent in inflammation and 
even only congestion of the nervous 
centres or their meninges ; and these 
symptoms are not rare in many other 
organic nervous diseases. 



5. The temperature of the affected 
parts is generally high. 

6. The sphincters of the bladder 
and rectum are often attacked with 
spasm or paralysis. 

7. An aura, felt or unfelt, never 
exists except when the organic dis- 
ease has caused a functional nervous 
affection. 

8. To remove the cause is often 
impossible, and, when possible, of much 
less importance than the direct treat- 
ment of the structural alterations. 



Other means of diagnosis between organic and func- 
tional nervous affections have been found within the 
last few years. As I shall have to speak of them at 
some length when treating particularly of certain func- 
tional nervous disorders, I will merely say here, that 
the most interesting amongst them are, — 



1. The effects of pressure on nerves, as employed by Dr. A. C. 

Pinel, Dr. Aug. Waller, and Messrs. Bastien and Vul- 
pian. 

2. The effects of tickling, and the degree and extent of reflex 

movements. 

3. The influence of galvanic applications. 



FUNCTIONAL NEKVOUS AFFECTIONS. 25 

4. The effects of strychnine as a test for congestion in the 

spinal cord and its meninges. 

5. The existence of anaesthesia limited to a small spot. 

6. The alteration in the speed of transmission of sensitive 

impressions. 

7. The existence of an unfelt aura. 



26 DIAGNOSIS AND TREATMENT OF 



LECTUEE II. 

ON MEANS OF SUPPRESSION OR DIMINUTION OF THE 
CAUSES OF FUNCTIONAL NERVOUS AFFECTIONS. 

Local applications of narcotics, of ice, and of the actual cautery. — Section 
of nerves. — Ablation of the clitoris. — Trephining of the cranium. — 
Ligature of the carotid artery. — Tracheotomy. — Cauterization of the 
urethra. — Various means of diminishing the reflex excitability of the 
nervous centres. — Means of producing sleep. — Mode of action of iron 
in improving nutrition. — Powerful influence of exercise. — Elimination 
of poisons. 

Gentlemen, — Great advances have been made within 
the last ten or fifteen years in the treatment of func- 
tional nervous affections. Our progress in that most 
important branch of medicine has, however, been much 
greater as regards a more rational or better-appropri- 
ated employment of medicines and other modes of 
treatment, than by the discovery of new remedies. 
During the same period, there has been also another 
kind of progress in our therapeutics : it is the rejection 
of certain modes of treatment, or the limitation of their 
use to fewer but more proper kinds of cases than pre- 
viously. 

Of the many kinds of advance of our knowledge in 
the treatment of functional nervous affections, I will 
group into three classes those which relate to the prin- 
cipal means of suppression or diminution of the causes 
of nervous disorders. In the first of these classes I 



FUNCTIONAL NERVOUS AFFECTIONS. 27 

will place various local applications, and different opera- 
tions on nerves, on arteries, &c. ; in the second will be 
ranged the means of diminishing the reflex excitability 
of the nervous centres ; and in the third, I will place 
means of improvement of blood, and of elimination of 
morbid and other poisons. 

I. ON LOCAL APPLICATIONS AND CERTAIN OPERATIONS EM- 
PLOYED TO SUPPRESS OR DIMINISH THE INTENSITY OF 
SOME CAUSES OF NEUROSES. 

When functional nervous affections are due to an 
evident irritation of a branch, or of the terminal rami- 
fications of a nerve of a limb, or a superficial nerve of 
the abdomen or chest, several means of treatment may 
be successfully employed to check or to cut off the 
irritation. I will say a few words on the most impor- 
tant of these means. - 

1. Local applications of narcotics. — In cases of 
epilepsy, of tetanus, of hysteria, and most other func- 
tional affections of the nervous system, a wound of the 
skin or of a branch of a nerve may be the cause of 
the nervous disorder. Narcotics, and particularly salts 
of morphia and atropia, employed together, should be 
applied on the wound itself, in doses varied according 
to the absence or the abundance of suppuration. An 
important rule of this mode of treatment is, that the 
application of narcotics must be frequently renewed, 
particularly if there is an abundant discharge of pus. 
If the cause of a functional nervous affection is the 
division of a large branch or of a trunk of nerve, an 



28 DIAGNOSIS AND TREATMENT OF 

injection of a solution of morphia and atropia should be 
made at some distance from the wound in the subcu- 
taneous cellular tissue, along the central part of the 
divided nerve (half a grain of a salt of morphia with 
one-thirtieth of a grain of a salt of atropia). 

2. Local applications of ice. — I have long ago 
pointed out the usefulness of this mode of treatment 
in cases of wounds producing a functional nervous 
affection. I will only say here, that when such a means 
is employed, particularly in a case of tetanus, there 
should be no interruption in the presence of ice on the 
wound during the whole of the time that the nervous 
affection lasts. Billroth has recorded two cases in 
which traumatic tetanus has appeared, notwithstanding 
the application of ice on the wound. It is probable, 
that, in these cases, there has been some interruption 
in the application of ice. 

3. Application of the actual cautery. — This means, 
which may be useful when it is necessary to alter the 
nature of the secretions in a wound, or to destroy parts 
of tissues containing a venom, has not generally so 
much value as either the preceding or the following 
modes of treatment. 

4. Various applications on the trunk of nerves at some 
distance from a wound. — It may be useful to lay bare 
the nerve that gives filaments to the wounded part, and 
to apply sulphuric ether or narcotic alkaloids or ice 
upon it. In cases in which there is reason to expect 
that the original wound will soon heal, this mode of 
treatment might prove useful. 



FUNCTIONAL NERVOUS AFFECTIONS. 29 

5. Section of a nerve. — The number of cases of 
epilepsy, of tetanus, and of other nervous complaints, 
due to a wound, a burn, &c., in which this mode of 
treatment has proved quite successful, is now so large, 
that there is no doubt as regards its immense value. It 
is most important to know that the operation must be 
performed early, as its chances of success decrease rap- 
idly with the prolongation of functional nervous affections 
produced by a wound, a burn, or some other peripheric 
causes of irritation. It is necessary, not only to divide 
the nerve completely, but to take away a small part of 
its peripheric end, which is to be examined carefully 
with the microscope to ascertain whether it is altered or 
not. If it is found inflamed, or otherwise altered, the 
operation must be repeated, whenever possible, on 
the same nerve, much nearer the spine or the cranium. 
The microscopical examination of a small part of the 
nerve extirpated in this second operation, will prove 
very important for the prognosis of the case. The fact, 
that a paralysis is a necessary result of the section of a 
nerve, can hardly be an objection against its perform- 
ance in affections like epilepsy, tetanus, hydrophobia, 
&c. Indeed, no sane man can have the least hesitation 
between these two things : on the one hand, an almost 
certain death, or the persistence of a fearful affection, 
which may produce imbecility ; and, on the other hand, 
a paralysis of motion and sensation in a part, or even the 
whole, of a limb. And the hesitation, if any can exist, 
would certainly give way to the knowledge, that the ends 
of a divided nerve, even when a small part has been ex- 



30 DIAGNOSIS AND TEEATMENT OF 

cised, will often unite soon, or within a year, and the 
paralysis be cured more or less completely. The rapid- 
ity of re-union of the ends of a divided nerve may be so 
great, that in a few weeks, and even sooner, there may 
be a partial return of function, as shown by cases 
reported by Mr. J. Paget 1 and by Mr. Syme. 2 As 
regards the completeness of the return of the vital 
properties in a divided nerve, I have seen that it may 
be as perfect as possible, particularly in the case of a 
nobleman, on whom Sir William Fergusson had divided 
the infra-orbitalis for a neuralgia. 

6. Operations on the genital organs. — An able 
English surgeon has lately treated several kinds of 
functional nervous affections by the extirpation of the 
clitoris. That this operation may sometimes be useful, 
there is no doubt at all. 3 But I cannot look upon this 
mode of treatment as one that should be employed in 
other cases than those in which a distinct aura starts 
from the clitoris, or in those cases in which that organ 
is morbidly sensitive and much hypertrophied. There 
are on record cases of nervous complaints, due to 
masturbation, in which the clitoris has been extirpated 
without any durable benefit as regards the nervous 
affection, or even as regards the habit of masturbation. 
In women, as well as in men, the only usually deci- 
sive means against masturbation is the production of a 

1 See " Lectures on Surgical Pathology," by James Paget, Lect. xii. 

2 See " Treatise on the Excision of Diseased Joints," by Prof. Syme, p. 88. 

3 I will, on this point, refer to a good paper recently published by Dr. H. R. 
Storer, in which he advances views very similar to my own as regards the fre- 
quency of onanism in women, and its treatment. See " The Western Journal of 
Medicine," of Indianapolis, for 1867, vol. ii. p. 440. 



FUNCTIONAL NERVOUS AFFECTIONS. 31 

small ulcer (by caustics or the red irou) on parts of the 
genital organs that are unavoidably touched or moved 
in the act of self-abuse, so that every attempt to accom- 
plish the act, either with or without the help of the 
hand, is so painful that the patient must give it up. 
Even this means, however, does not always prevent 
onanism. Indeed, I have seen a case in which the mere 
touch of the glans (which was inflamed and covered 
with pus) made the patient scream from the intensity 
of the pain, and in which, however, masturbation was 
practised several times a day. 

As regards the removal of the testicles, it seems to 
me a barbarous operation, if performed only because 
there is an excessive tendency to sexual intercourse. 

, 7. Trephining of the cranium. — As a mode of treat- 
ment against epilepsy, this operation has been much 
more frequently performed than is generally known. It 
has also been made, and with success, by Professor E. 
Geddings, of Charleston, in a case of tetanus, due to 
an irritation of the dura mater by a broken piece of 
bone. 1 Trephining of the cranium has also been 
successfully performed by Mr. Henry Lee, of London, 
in a case of reflex ulceration of the skin of the arm 
and spasmodic movements of the same limb. 2 It would 
be out of place here to discuss fully the question of the 
usefulness of that dangerous operation as a means of 
treatment of epilepsy. I will merely say, that it is only 
in cases of an irritation of the dura mater, by a broken 

1 See " The American Journal of the Medical Sciences/' Jan., 1853, p. 272. 

2 See Dr. Beale's " Archives of Medicine," 1860, p. 90. 



32 DIAGNOSIS AND TREATMENT OP 

piece of bone, by diseased bone, or any other evident or- 
ganic cause, that trephining can rationally be performed ; 
and that, even in such cases, a cure might be obtained 
(and has really been sometimes obtained) by the use of 
counter-irritation applied on the diseased spot. 

8. Ligature of the carotid artery. — This most irra- 
tional mode of treatment is, or I hope will soon be, 
completely abandoned. It has been employed in 
epilepsy and in mania, with the view that those affec- 
tions depend on a congestion of the brain, and that a 
ligature round the carotid artery would diminish that 
congestion. I will show, in a new edition of my work 
on " Epilepsy," that the good effects of this operation, in 
the cases of Preston and his imitators, have been obtained 
chiefly through some injury to the cervical sympathetic 
nerve. 

9. Other operations for the removal of causes of func- 
tional nervous affections. — I will only point out the im- 
portance of the removal or expulsion of a decayed tooth, 
of a tumor, of a carious or necrosed bone, or of worms 
in the bowels or vagina, in those cases in which there is 
a probability that these sources of irritation are the prin- 
cipal causes of a nervous complaint. Of other operations, 
such as tracheotomy and the cauterization of the ure- 
thra, I will only say a few words. It is now perfectly 
established, that the theory of epilepsy given by Mar- 
shall Hall was wrong ; and that, if tracheotomy may be 
useful in some cases of epileptic coma, or spasm of the 
glottis, in tetanus, in hydrophobia, or in whooping- 
cough, &c, this operation in those cases is of service 



FUNCTIONAL NERVOUS AFFECTIONS. 33 

against an effect, and not against a cause, of the exist- 
ing nervous affection. As regards the cauterization of 
the urethra, according to Lallemand's plan, in cases of 
nervous complaints due to seminal losses, I must say, 
that I have been consulted by a great many patients 
who had vainly submitted themselves to that operation ; 
while I have often observed a considerable amelioration, 
and sometimes a cure, by a medicinal and hygienic 
treatment, consisting in the use of atropine, the ergot of 
rye, large doses of the bromide of potassium, and nervine 
tonics, — such as quinine, iron, manganese, silver, — with 
cold, shower, and sitz baths, gymnastic exercise, and the 
most nourishing alimentation. 

10. Treatment against visceral diseases. — I only 
wish to point out under this head, that every organ, or 
part of an organ, in so far as it has nerves, and also if 
it has any marked influence on the composition of the 
blood, can be the cause of a functional nervous affection. 
Therefore an alteration of such an organ must be ener- 
getically fought against in these nervous affections, par- 
ticularly when no other cause of it can be found but 
that alteration. 

II. MEANS OF DIMINISHING THE REFLEX EXCITABILITY OF 
THE NERVOUS CENTRES. 

An increase of the reflex excitability of some part 
of the nervous centres is one of the most important ele- 
ments of many neuroses, and particularly epilepsy, hys- 
teria, tetanus, hydrophobia, delirium tremens, chorea, 
paralysis agitans, and some forms of reflex insanity. 



34 DIAGNOSIS AND TREATMENT OF 

To diminish that increase of reflex excitability is an 
essential part of the treatment in those affections. The 
following remedial agents are to be employed against 
this morbid state : — 

1. Codeine, narceine, morphine, atropine, valerian, 
aconite, the chloride of barium, the bromide of potas- 
sium, the bromide of ammonium, and turpentine, are 
undoubtedly the most reliable remedies against an in- 
creased reflex excitability. According to the kind of 
nervous affection, and also to the seat of the increase of 
that vital property, we are to select either one or another 
of these remedies. Atropine, valerian, and the bromides 
of potassium and of ammonium, are the most valuable 
in epilepsy ; the chloride of barium is of real value 
against tetanus and paralysis agitans, but of no use in 
the common forms of epilepsy ; codeine, narceine, mor- 
phine, and valerian are useful against hysteria, &c. 
None of these remedies, however, equals chloroform; but, 
unfortunately, its influence is merely transitory. Coun- 
ter-irritants and the warm bath have also a great power 
against the increased reflex excitability, as I will show 
in another lecture. 

2. As a morbidly increased excitability is very often 
due to anaemia or to an impoverished nutrition, all the 
hygienic and medical means (good food, exercise, and 
tonics) that can improve nutrition should be ordered in 
such cases against that morbid state. 

3. It is of the utmost importance to improve sleep, 
which is generally very bad in patients attacked with a 
morbid increase of the reflex excitability. For this pur- 



FUNCTIONAL NERVOUS AFFECTIONS. 35 

pose, an invaluable remedy has recently been discovered : 
it is the bromide of potassium. Excepting when pain 
is one of the causes preventing sleep (in which case the 
alkaloids of opium, aconite, or hyoscyamus should be 
employed), I have found that this remedy has a most 
wonderful power to produce a quiet and refreshing sleep, 
without any drawback that I am aware of. 1 I usually 
give to adults a dose of thirty grains of that salt a quar- 
ter of an hour before the last meal, and a second dose of 
from thirty to fifty grains at bed-time. In cases in which, 
without any nervous complaint, there is sleeplessness, 
owing to some cause of cerebral excitement, as well as in 
all neuroses, excepting hydrophobia, tetanus, very severe 
cases of delirium tremens, and some forms of insanity, 
I have ascertained that a sound and refreshing sleep is 
almost always induced by that remedy. In some cases, 
I have found it necessary to increase the dose of the 
bromide, and to give also a small dose of narceine or 
codeine an hour before bed-time. In those affections 
in which the bromide of potassium is not powerful 
enough as a sleep-inducing agent, a warm bath of four, 
five, or six hours' duration, is often successful. 

III. IMPROVEMENT OF THE BLOOD, AND ELIMINATION OF 
CERTAIN POISONS. 

It is now well known that all the morbid states of 
the blood can produce functional nervous affections. I, 



1 See Dr. H. Behrend's paper on this subject in " The Lancet " for 1864, 
vol. i. p. 607. — Dr. B. himself was attacked with sleeplessness, and was quickly 
cured, under my advice, by the use of the bromide of potassium. 



6b DIAGNOSIS 4ND TREATMENT OF 

therefore, need not stop long to prove, that anaemia, or 
the presence of morbid or other poisons in that liquid, 
often engender the worst as well as the slighter forms 
of nervous disorders. Since the publication of Marshall 
Hall's views on the effects of loss of blood, 1 we have 
learned much as regards the influence of anaemia in the 
production of nervous affections. In an admirable and 
too little-known work of the late lamented Dr. O. Lan- 
dry, 2 cases are recorded, showing how various are the 
forms of nervous disorders caused by an insufficiency of 
the amount of blood in the system, or by an alteration in 
the qualities of that nutritive fluid. The various forms 
of insanity, paralysis of sensibility or motion, neuralgia, 
and almost all the convulsive affections, from chorea to 
epilepsy and catalepsy, are among the often-observed 
effects of anaemia, whether due to a loss of blood, or to 
other causes. I must, however, warn the student of the 
physiology and pathology of the nervous system against 
admitting, that the convulsions observed at the time of 
impending death from haemorrhage are to be consid- 
ered as a genuine epileptic fit. Kussmaul and Tenner 3 
have committed a great mistake, in admitting that the 
fits they observed in their interesting experiments on 
animals were epileptic fits. The convulsions in those ani- 
mals, as in our own species in similar circumstances, i.e. 

1 See his " Essay on the Hydrocephaloid Disease in Children," and his 
" Observations on the Due Administration of Bloodletting, and on the Curative 
Effects of the Loss of Blood." 

2 " Becherches sur les Causes et les Indications Curatives des Maladies Ner- 
veuses," Paris, 1855. 

3 See the translation of their work " On Epileptiform Convulsions from Haem- 
orrhage," published by the New Sydenham Society, 1859, vol. v. pp. 1 to 109. 



FUNCTIONAL NERVOUS AFFECTIONS. 37 

occurring immediately after a considerable loss of blood, 
are due, as I will prove in another lecture, to the irri- 
tation of the nervous centres by the carbonic acid which 
then accumulates in the blood that remains in the 
system. In other words, convulsions are then due to 
asphyxia, and not to an alteration of nutrition, which 
cannot take place in a few minutes. 

There is no general rule of treatment against the 
various morbid states of the blood, producing nervous 
affections, beyond this self-evident one, that the best 
means to improve the condition of that fluid should be 
employed, together with the special means of treatment 
oY the particular nervous affection caused by the morbid 
condition of the blood. Ansemia, rheumatism, gout, 
diphtheria, scarlatina, syphilis, &c, are to be treated in 
the same way, whether they are or not the causes of a 
functional or organic nervous affection. 

I will only make a few more remarks on this subject. 
Modes of treatment consisting in attempts to furnish to 
the blood substances which are deficient in quantity, 
either in that fluid itself or in the tissues (such as iron in 
cases of chlorosis and anaemia, or phosphorus in certain 
nervous affections, and in cases of seminal losses), or to 
prevent certain secretions (as that of sugar in diabetes), 
are gradually being replaced by sounder therapeutic 
principles, grounded on a better knowledge of the causes 
of the alterations of the blood, or of nutrition and secre- 
tion, and also on a better appreciation of the immense 
value of hygienic means to improve the condition of the 
blood, and of the great organic functions. For instance, 



38 DIAGNOSIS AND TEEATMENT OF 

it has been shown by Sandras, Dalpiaz, Becquerel, Eis- 
mann, and others, that chlorosis is a nervous affection ; 
and that the deficiency of iron in the blood of chlorotic 
patients is an effect instead of a cause, as this deficiency 
occurs only after this affection has existed some time. 
It has been further shown, that iron serves to cure that 
affection, chiefly on account of a peculiar influence which 
causes the food to be transformed more easily into blood, 
and probably, also, of a direct improvement in the nutri- 
tion of the nervous centres. Other metals, which are 
not normal constituents of blood-globules, especially 
manganese and silver (particularly the oxides of these 
metals), sometimes act better than iron in cases of chlo- 
rosis and anaemia. He who will read attentively the 
remarkable papers of Professor Bouchardat on the pugi- 
list's training, and on the rapidly curative effect of exer- 
cise and good food in diabetes, 1 will soon be convinced 
of the immense value of purely hygienic means in im- 
proving nutrition and secretion. It is quite natural, 
therefore, that gradually the idea is being abandoned, 
that, whenever a principle is diminished in quantity in 
the blood or in the tissues, the best treatment consists 
in trying to increase its amount by giving as a rem- 
edy the deficient substance. Consequently the selection 
of a remedy as a tonic or a stimulant ought to be quite 
independent of any such chemical view ; and we ought 
to let a good diet, and all the principal rules of hygiene, 



1 See " Supplement a l'Annuaire de Therapeutique pour 1861," and the paper 
on the " Treatment of Diabetes," pp. 291-336, in "L'Annuaire de Therapeutique 
pour 1865." 



FUNCTIONAL NERVOUS AFFECTIONS. 39 

take care of the composition of the blood, when its mor- 
bid condition consists only in the deficiency of globules 
or albumen, — remembering, however, that it may be 
useful to the patient to employ the kinds of food which 
we know to contain, in easily absorbable forms, iron, 
phosphorus, or some other substance which seems to be 
in insufficient quantity in the blood or in the tissues. 

As regards the elimination of mineral poisons which 
have produced functional nervous affections, I will only 
say at present, that the discovery of Melsens, which 
shows the value of large doses of the iodide of potassium 
for the expulsion of lead and mercury from the system, 
has been universally recognized. It is important to re- 
member, that the dose of that salt must be very large for 
its successful influence. The statements of Melsens and 
N. Guillot on this point have received positive confirma- 
tion from researches by Dr. W. Budd, of Bristol, and 
Professor Easton, of Glasgow. 1 My own observations 
agree with the conclusions of these able physicians. 
The elimination of lead and mercury takes place chiefly 
by the urinary, salivary, and cutaneous secretions. Con- 
sequently, saliva must be spit, and the skin very fre- 
quently washed, in order to avoid a partial absorption of 
these poisons after they have been secreted. 

1 In a second paper, Melsens says, that, at first, the dose should be small, to 
avoid the solution of too great a quantity of lead or mercury, which might prove 
injurious. I do not agree with him on this point ; but I think, that the doses, 
however, should not be as large at first as after a few days. I think also, that, 
instead of two or three doses a day, five or six should be given, in those special 
cases of nervous affections due to lead or mercury. See Melsens's second paper 
in "Journal de Chimie Medicate," 1849, p. 136; W. Budd's paper in "British 
and Foreign Medico-Chirurgical Review," 1853, vol. xi. p. 202 ; and J. A. Eas- 
ton's paper on Elimination, in " Glasgow t Medical Journal," July, 1858, p. 152. 



40 DIAGNOSIS AND TREATMENT OF 

I will not speak of the elimination of morbid poisons 
(such as those of diphtheria, rheumatism, gout, syphilis, 
leprosy, &c.) having produced nervous affections, be- 
cause nothing of great importance has been found re- 
cently that applies to all, or almost all, those poisons. 
The only fact worth mentioning is, that the iodide of 
potassium may serve for the elimination of all but one 
of them. 



FUNCTIONAL NERVOUS AFFECTIONS. 41 



LECTURE III. 

ON MORAL, PHYSICAL, AND VARIOUS OTHER MODES OF 
TREATMENT OF FUNCTIONAL NERVOUS AFFECTIONS. 

Importance of a serious mental occupation. — Means of increasing and of 
decreasing the quantity of blood in the limbs, the trunk, or the head. — 
Irritation of nerves of the skin and other peripheric parts, as a means of 
curing a morbid state of the nervous centres.- — Therapeutic use of cold 
and heat. — Cauterization of fauces and larynx. — Baths. — Pressure on 
the carotid artery. — Special treatment of periodical affections. — Special 
use of anaesthetics. 

Gentlemen, — I will divide the subject of this lecture 
into six parts : the first, on moral treatment ; the second, 
on physical and mechanical means of treatment ; the 
third, on therapeutic means, acting through an irritation 
of sensitive and other incident nerves ; the fourth, on 
complex modes of treatment, combining the two pro- 
cesses of irritation of nerves and a modification of 
blood ; the fifth, on special modes of treatment in peri- 
odical nervous affections ; and the sixth, on a special use 
of an s&s the tics. 

I. MORAL MEANS OF TREATMENT. 

Under this head I will say only a few words here 
concerning two general principles of therapeutics, which, 
notwithstanding their importance, are very much neg- 
lected. The first of these principles, so well established 



42 DIAGNOSIS AND TREATMENT OF 

by the researches of Dr. Cerise, 1 is, that a serious aim 
in the daily occupations is of the greatest value, and, 
for many persons, quite essential to prevent or to check 
nervous disturbances. The applications of this princi- 
ple are, of course, very difficult, and often impossible, in 
certain neuroses ; but in those cases in which any kind 
of serious work, either mental or physical, but not too 
fatiguing or exciting, is liked by the patient, he should 
be induced to do it. In cases of hypochondria, of hys- 
teria', of chorea, and even of epilepsy, a great benefit 
can be derived from a serious employment of the men- 
tal and physical activity of the sufferer. How often 
have I not seen young epileptics kept in idleness (alas ! 
by medical advice), and, having gained more or less of 
the vices it leads to, improve rapidly from having their 
minds occupied at regular hours, in nearly the same 
way as healthy people of their age ! 

The second principle of moral treatment is, that we 
must, in the interest of our nervous patients, as much as, 
if not more than, in our own, give them confidence and 
hope in the treatment we recommend. In hysterical 
and all nervous complaints allied with it, and also in 
hypochondria, and in several other neuroses, a great 
hope of cure will do much to work out the cure. No 
doubt you will say, How to give hope ? I answer, that 
the best means for that purpose is to have hope our- 
selves, and to express our hope with the accent of con- 
viction. And as you would ask, How can we command 



1 See his excellent work, " Des Fonctions et des Maladies Nerveuses," Paris, 
1842. 



FUNCTIONAL NERVOUS AFFECTIONS. 43 

hope in ourselves 1 I answer, that the very knowledge 
of the truth of the principle I am now speaking of is 
enough to render one hopeful. I need not repeat, that 
I am now speaking only of those neuroses in which the 
power of the mind upon the body is so great, that under 
the influence of an emotion, or another moral cause, a 
sudden or almost sudden cure is not very rare. 

II. PHYSICAL AND MECHANICAL MEANS OF TREATMENT. 

Although the therapeutic means of this class are not 
very new, most of them are so generally neglected, 
notwithstanding their great value, that I must say a 
few words about them, especially to show in what way 
and in what cases they should be employed. 

1. Means of increasing the quantity of blood in peri- 
pheric parts of the body. — In all cases of diminution 
of size and density in muscles attacked with reflex 
paralysis, lead palsy, paralysis agitans, rheumatic para- 
lysis, or idiopathic and reflex wasting palsy, as well as in 
cases of anaesthesia with diminished temperature of the 
skin, it is very useful to increase the quantity of blood 
in the paralyzed, the trembling, or the anaesthetic parts. 
For this purpose, the best mechanical and physical 
means are the following : — 

1. When the affected part is not extensive, dry-cup- 
ping, with the ordinary apparatuses, may be resorted to 
with advantage, particularly in cases of local hysterical 
anaesthesia, with great coldness of the skin. 

2. Junod's boots to be applied every other day, either 
to a whole arm or to a whole lower limb, when there is 



44 DIAGNOSIS AND TREATMENT OF 

no oedema. It is chiefly in cases of paralysis, with wast- 
ing of muscles (not, however, the idiopathic wasting 
palsy), when the loss of motion is not due to an organic 
disease of the nervous system, that I have witnessed 
a great amelioration from the use of this powerful 
means of increasing the amount of blood in a limb. 
As regards the modus agendi of that therapeutic means, 
I have ascertained, by experiments on animals, that 
muscular irritability increases whenever the quantity of 
blood is augmented in muscles ; and I have found, that, 
in a limb of an animal dry-cupped for eight or ten 
minutes by Junod's boot, muscular irritability acquires 
a much greater degree than before the application of 
the boot. 

3. Covering the affected part with heated flannel or 
woollen stocking or sleeve. 

4. Shampooing, without uncovering the part, if the 
temperature of the room is low. 

5. Frictions with a hot piece of flannel only in the 
direction of the venous current. 

6. The affected part should be kept as much as pos- 
sible in a lower position than that of the rest of the 
body. 

7. Applications of ice should also be made, according 
to rules to be given hereafter. 

2. Means of diminishing the quantity of Mood in the 
trunk and head without bleeding. — It may be necessary 
to employ means of this kind in the comatose state 
existing sometimes in certain functional nervous affec- 
tions, such as epilepsy, eclampsia, delirium tremens, 



FUNCTIONAL NERVOUS AFFECTIONS. 45 

or in nervous disorders due to uraemia, cholesteraemia, or 
some other kind of toxaemia. Junod's boots may an- 
swer the purpose ; but there is a simpler means, which 
has the great advantage of being everywhere at hand, 
and is superior to these cupping boots in this respect 
also, that it may be applied with hardly any interruption 
for hours and days, if necessary. This means consists 
in the application, on the upper part of the four limbs, 
of ligatures tight enough to diminish considerably the 
return of blood to the heart, without preventing much 
the arrival of blood. By so doing, a pretty large amount 
of blood may be imprisoned in the limbs, and all the 

m 

immediate benefits of bleeding can be obtained ; while 
the bad effects it may have exist only during the time 
the ligatures are kept on the limbs. In making use of 
this means, it is important to loosen the ligatures every 
fifteen or twenty minutes, and to apply them in a new 
place after each loosening. To avoid the danger of 
a sudden return of a great deal of blood, they must 
be removed successively, and an interval of at least a 
few minutes must be left between two succeeding re- 
movals. 

3. Means of increasing the amount of blood in the 
trunk and head. — It may prove necessary, or at least 
useful, in some cases of syncope (in hysteria, in epilepsy, 
and in a few other neuroses due to anaemia, chlorosis, 
&c), to increase the amount of blood in the trunk. In 
addition to the so-well-known means of laying the pa- 
tient fiat on his back, his head left on the level of his 
body, and his four limbs lifted up, so as to have the help 



46 DIAGNOSIS AND TREATMENT OF 

of gravitation for the accumulation of blood in the trunk 
and head, it seems of real importance to press with the 
hand or with a tourniquet on the main arteries of the 
four limbs, near their place of issue from the trunk. 
Besides these means, it is of great importance to excite 
the heart to beat by frequently repeated pressure on 
the sternum and ribs directly over that weakened organ ; 
as I have ascertained, on various species of animals, that 
when the movements of the heart have just ceased, in 
consequence either of a reflex action from an irritation 
of the abdominal sympathetic nerve, or of a direct exci- 
tation of the medulla oblongata or par vagum, a pressure 
upon that organ (i.e. a direct mechanical stimulation) 
will make it beat again. 1 

4. Other mechanical and physical means. — I will not 
speak now of the pressure on the carotid arteries, or on 
nerves, as these means are not simply mechanical. The 
same reason makes me postpone what I have to say of 
the application of ligatures round a limb or some other 
part, in cases of an aura epileptica or hysterica, &c. I 
will now say only, that when an attack of epilepsy, of 
eclampsia, &c, is followed by a comatose state, or even 
a sleep with heavy breathing, it is of the greatest impor- 
tance to place the head of the patient in such a position, 
that the tongue, which is then nearly paralyzed, will not 
fall on the larynx, and cover its aperture 



1 There is a most powerful means of exciting the heart to beat in cases of 
partial syncope, which I do not mention in the text, because it is not mechanical. 
It consists in stopping completely the breathing of the patient for one-half or 
two-thirds of a minute. The blood then becomes more charged with carbonic 
acid, and more exciting to the heart. 



FUNCTIONAL NERVOUS AFFECTIONS. 47 

III. ON THERAPEUTIC MEANS, ACTING THROUGH AN IRRITA- 
TION OF THE SENSITIVE AND OTHER INCIDENT NERVES. 

These means are of the utmost value ; and the recent 
progress of our knowledge as regards their mode of 
action constitutes a large part of the advance of the 
therapeutics of neuroses in our time. These means act 
chiefly by a reflex action ; most of them on the vaso- 
motor nerves, and some of them on the nutritive and 
secretory nerves. Many of them give a sensation of 
pain, while they are applied or afterwards ; but most 
likely their principal mode of action is through the 
irritation of the non-sensitive incident nerves (excito- 
motor of blood-vessels, and excito-nutritive and secretory 
nerves). I will state briefly what are the most interest- 
ing points concerning the therapeutic influence of these 
means. 

1. Ligatures, pinching, rubbing, and circular blis- 
ters. — When I first began to make use of ligatures in 
epilepsy, I had hardly any other than theoretical objec- 
tions against the view, that, in that convulsive affection, 
ligatures serve only to prevent the passage upwards of 
an irritation travelling from the periphery towards the 
nervous centres. I soon saw several cases similar to a 
few already known, in which the cause of the aura was 
clearly in the nervous centres, and in which, however, 
ligatures acted as marvellously in preventing attacks as 
in cases in which an aura had undoubtedly its cause in 
a peripheric part. 

When the extremely various sensations which accom- 



48 DIAGNOSIS AND TREATMENT OF 

pany an aura, 1 in the same manner as the aura itself, 
have their only cause in the nervous centres, as it was 
in the cases I have just mentioned, it is quite evident 
that there is nothing going from the periphery to the 
nervous centres ; and it is quite as evident, that ligatures 
in such cases must act by some other means than by 
preventing the passage of something. This first point 
being clearly established, I found that ligatures, in cases 
of an aura having a centric origin, acted with greater 
efficacy when they suddenly produced powerful irritation 
of the nerves of the skin, than when they were applied 
gradually and slowly, either tightly or not. After hav- 
ing made this step, I ascertained that it was so even in 
cases of an aura starting distinctly from the periphery. 
I found afterwards, that, in both kinds of cases, pinch- 
ing, pricking, striking, or rubbing the part which is ob- 
jectively or only subjectively the place of origin of an 
aura may prevent a fit of epilepsy or of hysteria, or 
simply of local or general convulsions. I was led, 
therefore, to look upon ligatures in those cases as acting 
chiefly as a means of irritation of the nerves of the 
parts on which they are applied,— -an irritation produ- 
cing a favorable change in the nervous centres. 2 The 
following results I have subsequently obtained : — 

1 I say, " accompany an aura," because I have found that the sensations 
which are miscalled aura are not at all essential, as they vary extremely, and 
may exist or be absent altogether ; the aura, notwithstanding their absence, 
being as powerful as any apparently felt aura can be. These sensations, therefore, 
which are erroneously considered as constituting the aura, are merely accidental 
phenomena which accompany the essential and special irritation which should 
alone be called aura. 

2 The influence of an external irritation in producing a favorable change in 
the nervous centres is beautifully illustrated in cases of myelitis existing in a 



FUNCTIONAL NERVOUS AFFECTIONS. 49 

1. That it is not necessary to apply an irritation 
(by a ligature, pinching, &c.) on the very limb from 
which an aura seems to start, as the same means ap- 
plied elsewhere may succeed ; but the chance of suc- 
cess is much greater by the former than by the latter 
way. 

2. That a constant or a frequent irritation (by a blis- 
ter, an issue, a seton, the actual cautery, &c.) on the 
place from which an aura seems to start, may not only 
prevent fits, but, by some change of nutrition locally 
(if the aura is really of peripheric origin) and in the 
nervous centres, may reduce or even destroy altogether 
the tendency to fits, and lead to a complete cure. 

3. That, as a circular ligature may procure a tempo- 
rary good effect, so a narrow circular blister applied 
all round a limb, a toe, or a finger, or a circular cauter- 
ization with a white-hot iron, may cure epilepsy, hys- 
teria, neuralgia, &c, in cases with a distinct aura. 

4. That, even in cases in which there is no known 
aura, felt or unfelt, ligatures, pinching, and other means 
of irritation, may prevent the occurring of expected fits. 
I ought to say, in addition, that, for a long while already, 
it has been known, — not generally, however, — that lig- 

small zone, in the upper or middle part of the dorsal region, leaving below it all 
or nearly all the dorso-lumbar enlargement of the spinal cord in a very congested 
but probably otherwise healthy state. In seven well-characterized cases of that 
kind that I have seen (alone or with Professors Trousseau and Nelaton, and Drs. 
Charcot and Verneuil, of Paris, J. S. RamskihVand Hughlings Jackson, of Lon- 
don, and Dr. L. R. Stone, of Newton, Mass.), there were, as usual in such cases, 
extremely violent and frequent reflex tetanic spasms in the lower limbs. In 
these seven patients, the spasms at once abated and quickly ceased, when the big 
toe of either of the feet was seized, and forcibly and suddenly drawn down, flexed 
as much as the ligaments of the joints would allow. I think the same means 
should be tried in tetanus, and particularly traumatic tetanus. 

6 



50 DIAGNOSIS AND TREATMENT OP 

atures, applied to one or two limbs, may prevent the ap- 
pearance of an expected attack of fever and ague. As 
malarial poison produces fever by a peculiar influence 
upon the spinal cord, the success of ligatures against 
fever and ague is probably due to a favorable change 
in that nervous centre, induced by a peripheric irrita- 
tion of incident nerves. 

2. Cold. — Ice is the most powerful means we pos- 
sess to produce a reflex contraction of blood-vessels. 
Before a positive demonstration was obtained, this mode 
of action had already been rendered extremely proba- 
ble, by the following well-known facts : that ice applied 
on the abdomen or on the back, or in the vagina and 
rectum, often stops a haemorrhage from the womb; 
that, applied to the head, it will do some good in 
cases of congestion or inflammation of the brain or 
its meninges, or in cases of symptomatic or idiopathic 
headache ; that it may stop a haemoptysis when applied 
to the chest, and a haemorrhage from the bowels, the 
stomach, or the kidneys, when applied to the abdomen 
or the loins; that it may be employed with marked 
benefit against an inflammation of the viscera or serous 
membranes of the chest and abdomen, and especially 
against puerperal fever and metroperitonitis, as shown 
particularly by Michaelis of Kiel, T. Helm, F. Kiwisch ; l 
that, applied all along the spine, it may cure tetanus, 
and be useful against spinal meningitis. 2 

1 See " The British and Foreign Medical Review " for 1837, vol. iv. p. 518 ; 
and for 1842, vol. xiii. pp. 108 and 120. 

2 The above facts have led me to propose (" Lectures on the Various Forms 
of Paralysis of the Lower Extremities/' 1861, pp. 91, 92) the use of pounded ice, 



FUNCTIONAL NERVOUS AFFECTIONS. 51 

These facts gave a great probability to the view that 
ice acts as an irritant of incident nerves, and, through 
the influence of this irritation transmitted to the spinal 
cord or to the base of the brain, produces a reflex con- 
traction of blood-vessels ; but, so far as I know, there 
was no positive fact demonstrating this peculiar mode 
of action of cold on blood-vessels, until the experiments 
which I made more than sixteen years ago, 1 with my 
friend Dr. Tholozan, clearly showed that ice can act 
in that way. We found that dipping one hand into 
water at freezing-point produces in the other hand con- 
siderable contraction of blood-vessels and a correspond- 
ing diminution of temperature. This fact, of which I 
shall have to speak again in another lecture, leaves 
hardly a doubt as regards the mode of action of ice in 
the cases in which it is daily employed with the view 
of producing a remote effect. Recently, Dr. Chap- 
man 2 has had the idea of applying ice to the spine, 
with the purpose of paralyzing the vaso-motor nerves 
of the limbs or of the head. He states that the appli- 
cation of ice to the lumbar region of the spine pro- 
duces a dilatation of the blood-vessels of the lower 
extremities, and all the consequences of a greater afflux 
of blood; and that a similar application between the 
shoulders produces the effects of the section of the two 
cervical sympathetic nerves. Whether he be right or 

to be applied in bladders all along the spine in cases of haemorrhage in the spinal 
canal. I have since then made a useful application of this mode of treatment in 
a case of that kind. 

1 See " Journal de la Physiologie de l'Homme et des Animaux " for 1858, 
vol. i. p. 497. 

2 Medical Times and Gazette, July 18, 1863. 



52 DIAGNOSIS AND TREATMENT OP 

wrong in his explanations, he at any rate relates facts 
which deserve to attract the attention of the profession. 
We are not frequently enough successful in our treat- 
ment of neuroses to neglect means which, according to 
his statements, have cured so many cases of epilepsy or 
of other nervous affections. It is to be hoped, there- 
fore, that physicians having charge of large hospitals 
will give a fair trial to the means he proposes, and as- 
certain the real value of cold applications to the spine 
in the treatment of neuroses. 

I will try to prove elsewhere, that the application of 
ice to the upper part of the spine chiefly acts like any 
other irritation of the skin, but with more power ; modi- 
fying remedially the nutrition of the nervous centres, 
and particularly that of the base of the'brain. A reflex 
influence on the circulation of blood and on the nutri- 
tion of the retina may also take place from the appli- 
cation of ice to the spine. A patient of Mr. Ernest 
Hart l has been cured of epilepsy and progressive 
atrophy of the optic nerve by applications of Chap- 
man's ice-bags to her spine. The same patient had pre- 
viously been under my care, and had derived only a slight 
benefit from the use of the valerianate of atropia. 

I wish it to be understood, however, that I do not 
recommend the use of Chapman's India-rubber ice-bags. 
I believe, that, in most cases in which ice is to be ap- 
plied, its influence is very much diminished by the inter- 
position, between it and the skin, of a pretty thick layer 
of India-rubber. In cases of congestion of the base of 

1 See " The Lancet/' London, January, 1865, vol. i. p. 6. 



FUNCTIONAL NERVOUS AFFECTIONS. 53 



• 



the brain or of the cerebral meninges, pounded ice must 
be applied almost on the bare skin, a thin linen only 
being placed between ice and the cutaneous surface. 
The same mode of application is also the proper one in 
cases of great coldness of feet in epilepsy, in hysteria, 
and also in cases of infantile paralysis and in lead palsy, 
and several other kinds of paralysis in adults. I have 
ascertained, that, in all these cases, rubbing with ice the 
skin of the legs, feet, arms, and hands, each part for ten 
minutes every day, very quickly improves circulation and 
nutrition, and increases notably and persistently the tem- 
perature of the parts that are so treated. The benefit 
of such applications is sometimes considerable, even in 
cases of paralysis from an organic disease, when there is 
a great coldness of the paralyzed parts. 

This would be the place to speak of hydrotherapy, if 
I had time to treat of all the therapeutical means. I 
will only say, that an important addition to the proofs of 
the reflex influence of cold water on blood-vessels has 
been obtained by Dr. L. Fleury, who, by careful meas- 
ures, has ascertained, that, after the application of a 
cold douche on the skin, a congested spleen or a con- 
gested liver will sometimes diminish in volume much 
more than had been stated by other practitioners. Sev- 
eral interesting facts lately observed by a talented young 
physician, Dr. Beni-Barde, give a confirmation to the 
view that the therapeutic influence of hydrotherapy is 
due to a reflex action on the internal organs from the 
excitation of the skin by cold water. 

3. Actual cautery and other educations of heat. — 



54 DIAGNOSIS AND TEEATMENT OP 

Jobert de Lamballe, 1 Valleix, 2 and others have ex- 
aggerated the advantages of the so-called transcurrent 
cauterization against neuralgia ; but there is no doubt, 
that this means is one of the most valuable in that affec- 
tion, and is very useful against other neuroses. I may 
say, that it is not at all necessary to produce a burn that 
will give a great discharge. If the iron employed has 
a smooth surface ; if, besides, it is applied only at white 
heat, and passed quickly over the skin with a gentle 
pressure, — it hardly gives pain. The epidermis and a 
very thin layer of the skin dry up and fall off within 
two or three days, leaving a reddish mark, which disap- 
pears before very long. This means I have employed 
with great advantage in a case of angina pectoris, and 
in many cases of epilepsy and neuralgia, and with some 
benefit in cases of contracture, of torticollis, of paraly- 
sis agitans, &c. The application of heat in many other 
ways (by Mayor's hammer, for instance) is very useful 
in a great many cases of nervous affections. In a case 
of coma with convulsions, due to a complete arrest of 
the urinary secretion after an attack of renal hematuria, 
in 1851, Dr. Tholozan and myself, after twenty-four 
hours of unsuccessful treatment, decided to apply heat 
on the skin of the loins and sides of the abdomen. A 
large silver spoon was dipped into boiling water, and 
was applied on eight or ten places. To our surprise 
and delight, we soon found the respiration improving ; 
and, in less than a quarter of an hour, the convulsions 

1 Etudes sur le Systeme Nerveux, Paris, 1838, vol. ii. p. 648. 

2 Guide du Medecin Praticien, 4 eme ed., Paris, 1860, vol. i. p. 656. 



FUNCTIONAL NERVOUS AFFECTIONS. 55 

ceased, and the patient came to his senses, and passed a 
little water. The return of the urinary secretion had 
saved him. 1 No doubt the irritation of the skin had 
acted by a reflex action on the secretory nerves of the 
kidneys, and produced the secretion of urine. 

4. Alternative applications of cold and heat. — Led 
by the well-known powerful influence of alternative im- 
mersions of newly born children into cold and warm 
water to restore respiration, I have often applied, with 
more or less good effect, cold and hot water to the spine, 
with a view of producing a contraction of blood-vessels 
of the spinal cord. Whether these vessels are already 
somewhat contracted, as is most likely the case in reflex 
paralysis or reflex anaesthesia, or dilated, as is often the 
case in hysterical paraplegia, some good may be ob- 
tained in these two opposite conditions from the use of 
cold and hot applications, owing to causes which I will 
explain in another lecture. I have found alternative 
applications of ice and hot poultices very useful against 
neuralgia. 2 A very able physician of London, Dr. J. S. 
Ramskill has obtained some benefit from alternative im- 
mersions of a paralyzed limb into very cold and hot baths. 



1 A few years afterwards, the patient, who was a physician, succeeded with 
me, by the same means, in saving the life of a patient who was attacked with 
cholera, aggravated by uraemic coma and convulsions. 

2 These alternative applications of ice (for ten minutes) and hot poultices (for 
an hour), which I long ago recommended as a means of preventing the forma- 
tion of bedsores and sloughs on the nates and elsewhere in cases of myelitis, 
spinal meningitis, or fracture or dislocation of the spine, typhus, &c, have now 
been so often employed successfully by myself and many other medical men, that 
I think I may safely say that these morbid alterations of nutrition might be al- 
ways prevented by those simple means. (See the valuable work of Drs. S. W. 
Mitchell, G. E. Morehouse, and W. W. Keen, on " Gunshot Wounds, and other 
Injuries of Nerves/' Philadelphia, 1864, p. 25.) 



56 DIAGNOSIS AND TREATMENT OF 

5. Cauterization of fauces and larynx. — A. man of 
some talent, who unfortunately allied eccentricity, if not 
charlatanism, to a genuine love of his profession, Dr. 
Ducros, 1 used to treat many nervous and other com- 
plaints by the application of ammonia to the fauces. 
More rational researches have shown, that a cauteri- 
zation of the fauces, and, still better, of the mucous 
membranes of the larynx or pharynx, is of the utmost 
value in the treatment of whooping cough, and other 
spasmodic affections of the larynx or bronchial tubes, of 
diphtheritic or hysterical paralysis of the larynx and 
pharynx, and in that form of epilepsy which is due to 
laryngismus. 2 

6. Acupuncture, electro-puncture, and faradisation. — 
As there is nothing new to be said about these means, I 
will only state, that they are among the most powerful 
against paralysis, and very useful against neuralgia, 
wasting palsy, contracture, chorea, trembling palsy, and 
some other neuroses. Acupuncture and electro-puncture 
are certainly too much neglected in our time. 

7. Other kinds of irritation of sensitive or incident 
nerves. — Many applications on the skin have a great 
power in changing the state of nutrition of the nervous 
centres or of the peripheric parts attacked with pain, 
spasm, &c. Of the means of treatment of this kind 
that have recently been proposed, I will only point out 
the use of nitrate of silver and of sulphuric acid on the 

1 Comptes rendus de l'Academie des Sciences, vol. xiii. p. 1150, vol. xv. 
p. 647, and vol. xvi. p. 1203. 

2 See Dr. Eben Watson's work on the " Topical Medication of the Larynx," 
London, 1854, pp. 103-104. 



FUNCTIONAL NERVOUS AFFECTIONS. 57 

skin in cases of neuralgia ; the use of the continuous 
galvanic current, as proposed by Remak, against many 
nervous affections ; and the singular but certainly some- 
times successful application of sulphuric ether into the 
auditory meatus against functional deafness. 

IV. COMPLEX MODES OF TREATMENT, COMBINING THE TWO 
PROCESSES OF IRRITATION OF NERVES AND A MODIFICA- 
TION OF THE BLOOD. 

Amongst the relatively new modes of treatment be- 
longing to this class, I will briefly mention a few, and 
speak at some length of only one. Tonic and exciting 
medicated baths — such, for instance, as a bath with 
sulphuret of potassium, or a bath with arseniate of 
soda — have been found very useful in chorea, and in 
most of the nervous affections due to anaemia, chlorosis, 
and rheumatism. 1 Turkish and Russian baths have 
proved useful in reflex paralysis, and in neuroses due to 
gout and rheumatism. Another mode of treatment, 
which deserves more than a cursory mention, may be- 
come, before long, of very great importance. Although 
its influence on the blood (at least in a direct way) is 
probably nil, I will speak of it now as it was at first 
considered as acting only through some change in the 
circulation of blood in the head. This mode of treat- 
ment, which has given, as yet, only a small part of the 

1 Four ounces of sulphuret of potassium are used for a bath. As regards 
the arseniate of soda, Dr. Noel Gue'neau de Mussy, who has often employed it 
lately, recommends its being used with subcarbonate of soda; 100 grammes 
(3^ ounces) of this last remedy, with one gramme (one scruple) of the arseniate, 
for a bath. 

7 



58 DIAGNOSIS AND TREATMENT OF 

good effects it can give, consists in a pressure on the par 
vagum and the cervical sympathetic nerve. It has been 
employed with the idea of diminishing the quantity of 
blood in the head by pressure on the carotid arteries ; 
and it has proved useful in cases of mania, of headache, 
of vertigo, and particularly as a means of shortening a 
fit of epilepsy. Dr. Alexander Fleming 1 has also made 
a successful use of that means to induce sleep. We owe 
to Dr. A. C. Pinel, and to that most ingenious and accu- 
rate physiologist, Dr. Augustus Waller, 2 the demonstra- 
tion, that the principal effect of an attempted pressure 
on the carotid artery is to irritate and put in play the par 
vagum, and diminish, consequently, the movements of 
the heart. My own researches show that the cervical 
sympathetic nerve also is often excited, as proved chiefly 
by the dilatation of the pupils. If the pressure is con- 
siderable, the effects of a section of the two nerves, 
but chiefly of the par vagum, are observed. 3 I will return 
to this subject in subsequent lectures ; adding only now, 
that we have, in the compression of the cervical sympa- 
thetic, a most valuable means against the form of 

epilepsy called petit mat. 

« 

1 See the " British and Foreign Medico-Chirurgical Keview," April, 1855, 
p. 404, American edition. 

2 See " Proceedings of the Koyal Society," London, 1861, vol. xi. p. 302. 

3 In performing this operation, it is important to avoid pressure on the veins 
of the neck or on the trachea, which parts have most likely been compressed in 
the cases described in the following extract from a work of Jacobi. There is " a 
feeling of burning heat, which spreads suddenly over the head and neck down 
to the chest ; or, when the compression was merely upon one side, over the cor- 
responding side of the head and neck, with a feeling of heat within the head in 
many cases. The face becomes darker, with frequently the production of a 
vivid color; an extremely painful sensation of compression of the chest; a feeling 
of tension, weight, and pain in the head ; giddiness, staggering, sleepiness ; ac- 



FUNCTIONAL NERVOUS AFFECTIONS. 59 

V. SPECIAL . MODES OF TREATMENT IN PERIODICAL NERVOUS 

AFFECTIONS. 

It is not my intention to speak now of the well-known 
useful influence of sulphate of quinine against perfectly 
periodical attacks of neuualgia, of epilepsy, &c. : I only 
wish to speak of a method of perturbation of the ner- 
vous system which I have employed with great advan- 
tage in some of those cases of local convulsions, of 
attacks of epilepsy, of hysteria, &c, which either recur 
nearly at fixed periods, or are preceded by a warning 
that gives time to make use of the means I will now 
mention. In a case of spasmodic attacks of muscles of 
the jaw and face, preceded by a sensation of pricking 
in the cheek, and occurring several times a day, in a boy 
seven years old, I found that violent exercise on a swing 
always prevented the fit, when the patient had time to 
run to, and make use of, the swing before the muscular 
contraction had begun. By that means, w x hich never 
failed, the boy was many hundred times saved from 
attacks, during more than two years that his nervous 
affection lasted. The cure occurred on the coming-out 
of a molar tooth, which, however, had not given the least 
pain. The cure has persisted, and the boy has become 
a full-grown man without any nervous disturbance anal- 
ogous to that of his childhood. The beneficial inilu- 

tual, sudden sleep, with stertorous breathing ; in many, incipient syncope, with 
uncertainty in the use of the lower extremities, stumbling ; and, in some cases, 
they suddenly fall down with entire insensibility, but speedily recover." ( Jacobi, 
" On the Nature and Treatment of Insanity," quoted in " British and Foreign 
Medical Review," 1846, vol. xxii. p. 14.) 



60 DIAGNOSIS AND TREATMENT OP 

ence of this or of almost similar modes of therapeutic 
perturbation of the nervous system I have observed since 
in a number of cases of hysteria and epilepsy. 

A great many other means of changing the state of 
the nervous system have been employed with some 
benefit by other physicians, or by myself. Among 
these means, I will merely mention here the follow- 
ing : A ligature round one or several limbs (even when 
there is no evident aura), tied strongly and suddenly ; 
a pretty sharp pinching of the skin ; a rather large 
dose of an emetic, taken with a great quantity of 
water ; a cold shower-bath on the back ; the applica- 
tion of an interrupted and powerful electro-magnetic 
current; a dose of twelve, fifteen, or eighteen grains 
of sulphate of quinine, about an hour before the ex- 
pected attack ; an enema of a drastic medicine ; the 
inhalation of chloroform, &c. I will give more details 
on these important perturbating means in some of the 
subsequent lectures. 

VI. SPECIAL USE OF ANESTHETICS. 

I have already said, that chloroform, taken by inhala- 
tion, may be useful, as a means of preventing an ex- 
pected attack of hysteria, of epilepsy, &c. I will now 
point out the importance of inhalations of chloroform 
in three particular kinds of cases. 

1. When the comatose state due to uraemia, or fol- 
lowing a violent attack of epilepsy, is frequently inter- 
rupted by tonic or clonic spasms of the respiratory 
muscles, increasing the profoundness and duration of 



FUNCTIONAL NERVOUS AFFECTIONS. 61 

the coma, I have employed inhalations of chloroform 
without any appearance of greater harm than is usual 
in surgical cases, and with the beneficial result of 
shortening the duration of the stupor by preventing the 
spasmodic contractions or diminishing their violence. 
This mode of treatment is known to be particularly 
useful in almost analogous circumstances;. i.e., in cases 
of puerperal convulsions. In many cases of epilepsy, 
in which a large number of attacks usually occurred in 
a day or a few days (such a series of seizures being 
followed by complete freedom from fits for three, four, 
or six weeks), and in which also a comatose state 
usually appeared soon after a few attacks had taken 
place, I have found the benefit due to chloroform to be 
very great ; the fits being much lessened in frequency 
and violence, the comatose state rendered shorter and 
less profound, and the period of great mental aberration 
after the cessation of the coma considerably dimin- 
ished. 

2. In the maniacal or delirious state due to hysteria, 
epilepsy, or uraemia, and also in cases of aggravated 
chorea preventing sleep, chloroform is of immense ser- 
vice, particularly if morphia, or some other somniferous 
remedy, is given to the patient, either by the hypodermic 
method or by injection into the rectum, as soon as chlo- 
roform has produced sleep. Dr. Briquet states, that, 
nine times out of ten, he has stopped attacks of hysteria 
by inhalations of chloroform. 1 I have not been quite so 
successful as Dr. Briquet in cases of hysterical convul- 

i See " Traite Clinique et The'rapeutique de l'Hysterie," Paris, 1859, p. 700. 



62 DIAGNOSIS AND TEEATMENT OF 

sions ; but I have ascertained that attacks of delirium 
and mania due to hysteria (and also to epilepsy) are 
almost always quickly brought to an end by chloro- 
form. 

3. In the case of a gentleman who had pretty regu- 
lar weekly attacks of epilepsy, I once employed chloro- 
form by inhalation, almost without interruption for two 
or three days successively, with the object of prevent- 
ing the expected fit or fits. It was of the greatest im- 
portance in that case to prevent a fit, as the patient in 
a preceding attack had fractured and dislocated one of 
his arms. The inhalations of chloroform saved, him 
from the expected attack, and the callus had time to be 
formed before he had another fit. This patient was 
seen with me by a very able physiologist and medical 
practitioner, Mr. Robert Dunn, of London. 1 

1 The details of this case have been published by Mr. Dunn in " The British 
Medical Journal," London, 1862, p. 140. The case is a remarkable one in more 
than one point of view. It shows the singular co-existence of. dislocation of the 
shoulder-joint with a fracture of the neck of the humerus, both accidents result- 
ing probably from a muscular contraction. 



FUNCTIONAL NERVOUS AFFECTIONS. 63 



LECTURE IV. 

GENERAL VIEWS ON THE MODES OF ACTION AND ADMINIS- 
TRATION, THE ANTAGONISM, ETC., OF REMEDIES USED 
AGAINST FUNCTIONAL NERVOUS AFFECTIONS. 

Difficulties in finding out the ultimate mode of action of remedies. — Thera- 
peutic analogies and differences of remedies. — Subcutaneous injections 
in cases of neuralgia and other neuroses. — Influence of chloroform in 
increasing the rapidity of cutaneous absorption. — Usefulness of sev- 
eral neglected methods of administration of remedies. — Advantages 
of alkaloids over extracts and other compounds. — Antagonism between 
belladonna, stramonium, hyoscyamus, quinine, on the one hand, and 
opium on the other. — Necessity of large doses of remedies against neu- 
roses. — Usefulness of association of certain remedies. — Rules of admin- 
istration of the bromides of potassium and of ammonium in epilepsy. — 
Mutual influence of certain narcotics upon each other. 

Gentlemen, — So great have been the recent ad- 
vances of our knowledge as regards the different points 
which are to be spoken of in this lecture, that a volume 
of considerable extent and importance might be written 
about them. I intend, however, to confine myself here 
to a short account of the principal and most useful facts 
relating to this branch of therapeutics. I will treat 
successively of the mode of action of remedies, and their 
analogies and differences, their administration, selection, 
antagonism, doses, and association. 

I. MODE OF ACTION OF REMEDIES. 

I have already mentioned the peculiar influence of 
remedies acting by an irritation of the skin. I will now 
briefly speak of their mode of action after they have 



64 DIAGNOSIS AND TREATMENT OF 

entered the blood, and been carried to the principal 
parts of the system, leaving details for other lectures. 

If we had only to learn what are the effects caused 
by remedies on the brain, on the spinal cord, on the 
heart, &c, we might think that the extent of our actual 
knowledge of the mode of action of remedies is truly con- 
siderable ; but if we are not contented with this partial 
knowledge, and wish to understand by what mechanism 
or what peculiar direct or indirect influence these effects 
are obtained, we find that very little is known yet on 
these most important points. This is much to be la- 
mented, as therapeutics will only cease to be empirical 
when this last kind of knowledge shall be fully ac- 
quired. 

We, however, have now good reasons to hope, that 
the time is not far distant when the ultimate mode of 
action of the most powerful remedies will be pretty well 
known. We shall then be enabled to employ them in 
those cases which can really be benefited by them, instead 
of ordering them blindly, as we now so often have to do, 
producing sometimes much more harm than good. 

Notwithstanding the great difficulties attending re- 
searches on the mode of action of remedies, I have, 
I repeat, a great hope that much will soon be done with 
regard to that important subject. This hope is grounded : 
first, on the results already obtained by several experi- 
menters on the mode of action of strychnine, of woo- 
rara, of veratrine, and a few other poisons and remedies ; 
secondly, on the fact that the difficulties to be surmounted 
are becoming more and more known, and that means of 



FUNCTIONAL NERVOUS AFFECTIONS. 65 

overcoming them have lately been found by physiolo- 
gists and by physicians. 

Among the difficulties, there are some depending on 
the number and variety of parts on which the remedies 
may act to produce their effects, and others due to the 
fact, that physiologists and toxicologists, in making re- 
searches on remedies, have almost always employed 
toxic doses. This last cause of error is especially unfor- 
tunate, as a number of remedies may have quite opposite 
actions in remedial and in toxic doses. 

As regards the number of parts on which remedies 
may act to produce their effects, I will show by a few 
examples what the difficulties are. Let us, for instance, 
try to find out on what part a remedy acts to produce 
the constriction of the pupil. It may do so either by 
paralyzing or by exciting certain parts of the nervous 
system or of the iris. If it paralyzes, it may be either a 
part of the spinal cord or medulla oblongata, from 
which originate the cervical sympathetic nerve, or that 
nerve itself in some part of its length from the eye to 
the spinal cord, or also the radiated or dilator muscular 
fibres of the iris. If its action takes place through an 
excitation, the part acted on may be the base of the 
brain near the origin of the third pair of nerves, or 
that of the fifth pair of nerves ; or it may be the iridian 
fibres of the third pair, or some fibres of the ophthalmic 
branch of the fifth pair of nerves ; and it may be also 
the annular muscular fibres or sphincter of the iris. 1 

1 See the valuable researches of Professor Donders and Dr. De Kuiter, on 
this subject, in Donders's work, " On the Accommodation and Kefraction of the 
Eye," London, 1864, p. 588. 



66 DIAGNOSIS AND TREATMENT OF 

The other kind of difficulty I have mentioned arises 
from the fact, that a remedy, in different doses, can pro- 
duce two opposite effects. Belladonna, for instance, by 
its influence on the blood-vessels of the spinal cord, 
will diminish sensibility, the reflex faculty, the tendency 
to convulsions, &c. ; but, when its dose is toxic, sensibility 
and the reflex faculty become morbidly increased, and 
convulsions occur. In both cases, probably, there is, at 
first, the same effect, — i.e., a contraction of the blood- 
vessels of the spinal cord ; but, in the second case, the 
contraction is so great, that the muscular fibres of the 
blood-vessels are soon exhausted, and become paralyzed, 
allowing a considerable congestion to take place in the 
spinal cord. 1 

In other lectures I will return to the subject of the 
action of remedies ; and I will now only refer those 
persons who desire to enter into original researches in 
this vast and fertile field of inquiry to an admirable 
paper that may serve as a model for such researches : I 
mean the paper published by MM. Martin-Magron and 
Buisson, on the "Action of Strychnine compared to that 
of Woorara." 2 



1 When blood-vessels in the ear and face of a dog are made to contract con- 
siderably by a very powerful galvanic excitation of the cervical sympathetic 
nerve, we find, that, after a short time, they are exhausted and paralyzed, 
which is evidenced by their becoming as much, if not more, dilated, as when their 
motor nerve is divided and paralyzed. 

2 See " Journal de la Physiologie de l'Homme," &c, 1859, vol. ii. pp. 473, 
584 ; and 1860, vol. iii. pp. 117, 323, and 522. 



FUNCTIONAL NERVOUS AFFECTIONS. 67 



II. ANALOGIES AND DIFFERENCES OF REMEDIES. 

The more we progress in our knowledge of the mode 
of action of remedies, the more we find that a priori 
notions, grounded on the chemical properties of the sub- 
stances which we try as remedies, are very rarely veri- 
fied. On the one hand, if we study the effects of salts 
of the same base or those of the same acid, we find 
that they vary extremely, even when the salts we com- 
pare are isomorphous, and possess almost identical 
chemical properties. On the other hand, there are sets 
of remedies which have no chemical resemblance what- 
ever, and which will, however, produce a great many 
similar effects. The recent advances of our knowl- 
edge as regards the action of belladonna, the ergot of 
rye, and the bromide of potassium, afford an interest- 
ing illustration of this statement. These remedies are 
useful against incontinence of urine, seminal losses, 
satyriasis, hyperesthesia (general or localized in the 
larynx or pharynx, the neck of the uterus, the sphinc- 
ters of the bladder and the anus, the urethra, &c.), epi- 
lepsy, whooping-cough, photophobia, constriction of the 
pupil, congestion of the spinal cord or its meninges, 
albuminuria, &c. There are, however, marked differ- 
ences in the degree of remedial power of these three 
substances against those morbid states. For instance, 
the ergot of rye is more powerful than the others 
against albuminuria and congestion of the spinal cord 
and its membranes ; the bromide of potassium is more 



68 DIAGNOSIS AND TREATMENT OF 

powerful than the others against epilepsy, satyriasis, 
&c. ; and belladonna against whooping-cough, hyperes- 
thesia, incontinence of urine, constriction of the pupil, 
photophobia, &c. Most of these remedial effects are 
evidently due to a contraction of blood-vessels, as are 
also other therapeutic effects, — such as the stoppage of 
haemorrhages and of the mammary and salivary secre- 
tions produced by belladonna and the ergot of rye. 1 

I will not say much as regards the differences of 
action of remedies which chemistry might lead us to 
suppose more or less similar, one to the other, in their 
remedial influence. The proofs of the dissimilarity of 
action of these substances are very abundant. I will 
only mention a few at random. If we compare the 
effects produced by the chloride of a base with those 
of an iodide or a bromide of the same base, we find that 
they differ widely. If, on the other hand, we compare 
the chloride of barium with another chloride, we find 
that there is also between them a very great difference 



1 I cannot say if the bromide of potassium would also be useful against a 
haemorrhage ; but this is exceedingly probable. For the sake of brevity, I 
have not given the names of the observers who have ascertained the usefulness 
of the three above-named remedies in so many nervous and other morbid states 
or affections. 1 think, however, I should say, — 1 st, That the influence of the bro- 
mide of potassium against photophobia has been particularly demonstrated by 
Messrs. Cambron and Rossignol, who use it as a collyrium (two parts for thirty 
of water) ; 2d, That Professor Von Willebrand has shown that the ergot of rye is, 
like belladonna, an excitant of the unstriped muscular fibres of the blood-ves- 
sels of the eye, and able, consequently, to diminish vascular congestion in that 
organ as in the spinal cord ; 3d, That Dr. Poyet and Dr. Commarmond have 
found, that rye-bread containing the ergot, like belladonna, stops the mammary 
secretion ; 4th, That the researches of Dr. Addinell Hewson, made on seventy- 
eight boys attacked with nocturnal involuntary emissions of urine, have given a 
decisive confirmation of the already known therapeutic value of both the bromide 
of potassium and belladonna in that affection. 



FUNCTIONAL NERVOUS AFFECTIONS. 69 

of action on the animal or on the human economy. 
So it is, although to a less degree, with the bromide of 
potassium, compared with the bromide of iron, 1 or even 
with the bromides of ammonium and sodium. 

I have mentioned these facts to show, that we are to 
look to experiments on animals, and to careful trials on 
man, to learn the physiological and therapeutical effects 
of remedies, and that chemical analogies cannot lead 
to any conclusion as regards the action of remedial 
substances. 



III. MODES OF ADMINISTRATION OF REMEDIES. 

One of the most important advances in therapeutics 
in our days consists in the method of subcutaneous in- 
jections of remedies. Led by the idea of applying nar- 
cotics directly on nerves attacked with neuralgia, Dr. 
Alexander Wood, of Edinburgh, opened this new field 
in therapeutics in 1855. 2 Since that time, many practi- 
tioners have found that hypodermic injections are often 
the best mode of administration of remedies, not only 
against local affections, but also against every form of 
functional nervous complaints, and also against gout, 
rheumatism, fever and ague, &c. Much credit is due 



1 Dr. Charles Bland Radcliffe has ascertained that the hromide of iron has no 
efficacy against epilepsy. My own trials lead to the same conclusion. 

2 The first paper of Dr. Wood was published in April, 1855, in " The Edin- 
burgh Medical and Surgical Quarterly Journal," p. 265 ; but his discovery had 
been made in 1843, i.e., long before this publication, and the method soon became 
generally known in Edinburgh. His second paper appeared in " The British 
Medical Journal " for August, 1858, p. 721. 



.70 DIAGNOSIS AND TREATMENT OF 

to Mr. Charles Hunter, of London, 1 for his researches 
on this new therapeutical method. To him, more than 
to any other investigator, we owe the solid grounding, 
if not the complete demonstration, of the three following 
propositions: 1. That equal effects follow distant and 
local injections in neuralgic cases. 2. That by distant 
injections (in various places) the ill-effects of repeated 
local injections are avoided. 8. That various affections, 
which are neither local nor neuralgic, can be treated 
with benefit by this plan. 

This method of administering remedies, which is now 
very extensively used, has very great advantages over 
most of the other methods. I will only point out a 
few of these advantages: 1. Rapidity of effect. 2. Cer- 
tainty that the remedy will not run the risk of being 
decomposed by food, secretions, or faeces, as may be 
the case in the digestive tube. 3. Possibility of intro- 
ducing safely into the circulatory system a much larger 
dose than by other methods. This last advantage is 
the principal one in the use of the hypodermic method 
against neuralgia. This explains how neuralgic patients 
who had taken apparently large doses of narcotics by 
the mouth, with no permanent and even no temporary 
marked benefit, are sometimes completely cured by one 
or by a few hypodermic injections of narcotics, — a fact 
which has been observed by Dr. Alexander Wood, Dr. 
Ruppaner, Dr. Behier, Mr. Charles Hunter, myself, 
and many others. 

1 See "The Medical Times and Gazette" for 1858 and 1859, and his 
pamphlet, " On the Speedy Relief of Pain and other Nervous Affections, by 
Hypodermic Injections," London, 1865. 



FUNCTIONAL NERYOUS AFFECTIONS. 71 

I have ascertained that a subcutaneous injection of 
purely narcotic substances is generally as useful when 
made at a great distance from the seat of pain (whether 
neuralgic or inflammatory) as when made on that very 
seat. Even in cases of traumatic neuralgia, I have 
seen, as Dr. Mason Warren * had before me, that dis- 
tant injections can be as good as local injections. I 
must say, however, that I have seen sometimes, in 
common cases of neuralgia, and* especially when I made 
somewhat irritating injections, that a better effect was 
obtained when the injection was made near the seat 
of pain than at a great distance from it. The differ- 
ence is probably due to the favorable influence of a 
counter-irritation acting, like a blister, a burn, &c, on 
some ramifications of the affected nerve, when the injec- 
tion was made in the locality of the pain or in its neigh- 
borhood. A new method of counter-irritation, which 
promises to be of great efficacy and which consists in 
sub-cutaneous injections of irritating substances, has 
lately been recommended by Dr. Luton. 2 The mere 
mechanical irritation by the pressure of a fluid may 
also have some beneficial effect. Indeed, I am told 
by a very intelligent and learned young physician, Dr. 
E. C. Seguin, of New York, that he has seen an 
evident good effect from an injection of pure water in 
some cases of neuralgia. 

Injections ought to be made in the cellular tissue sur- 
rounding the affected nerves, in cases of tetanus, hydro- 

1 American Journal of the Medical Sciences, for April, 1864, p. 323. 

2 Archives Generates de Medecine, Oct. et Dec, 1863, pp. 385 et 667. 



72 DIAGNOSIS AND TREATMENT OF 

phobia, epilepsy, or any other neurose due to a wound, 
as, in such cases, it is most important to obtain the benefit 
of the local action of the remedy on the wounded or irri- 
tated nerve-fibres (however little that may be), in addi- 
tion to the effect of the remedy after its passage into the 
blood. 

More than seven years ago, I was led, by the knowl- 
edge of the antagonistic effects of morphia and atropine 
on the brain, to inject these two agents together, so as to 
reap the benefit of the therapeutic effects of the one 
added to those of the other against pain. The doses I 
at first employed were half a grain of the sulphate of 
morphia to one-sixtieth of a grain of the sulphate 
of atropine. For reasons to be mentioned hereafter, 
I now employ from one-half to two-thirds of a grain 
of the sulphate of morphia with one twenty-fifth of a 
grain of the sulphate of atropine. Great advantages 
are obtained by this combination: 1. An addition of the 
good effects against pain of the two remedies ; 2. The 
possibility of employing safely, or at least without great 
or lasting cerebral or cardiac disturbances, large doses 
of these narcotics. 

The hypodermic method of administration of remedies 
has already proved useful in cases of headache, vertigo, 
delirium, mania, hysteria, epilepsy, eclampsia, chorea, 
tetanus, neuralgia, and all kinds of pain, &c. As re- 
gards the substances employed heretofore in injections, 
besides the two principal, morphine and atropine, I will 
only name strychnine, veratrine, narceine, quinine, and 
cyanhydric acid. This last remedy has especially been 



FUNCTIONAL NERYOUS AFFECTIONS. 73 

used, and with great benefit, by Dr. D. Macleod, in 
cases of acute and chronic mania, puerperal or men- 
strual mania, melancholia, and epilepsy. He employed 
from two to six drops of Scheele's diluted acid with 
thirty drops of water. 

The first interesting experiments of Dr. B. W. Rich- 
ardson, 1 by which he thought he had found a valuable 
mode of producing local anaesthesia, have led Dr. Aug. 
Waller 2 to a very important discovery. He found, that 
certain substances, such as atropine, strychnine, mor- 
phine, and the tincture of aconite, when mixed with 
chloroform and applied on the skin, are absorbed very 
rapidly ; while if alcohol, instead of chloroform, is mixed 
with the above substances, absorption is much delayed, 
or even altogether prevented. The possibility of in- 
troducing rapidly into the blood the most active nar- 
cotics and other remedies, without having to perform 
the operation of hypodermic injection, will prove of great 
value in those cases in which an operation, how- 
ever slight, is much dreaded, and in cases in which it 
may be found necessary to keep the patient for a long 
time under the influence of the treatment (for instance, 
in tetanus, in hydrophobia, in persistent neuralgic pains, 
&c.) 

Within the last ten or fifteen years, several facts of 
importance as regards the selection of the proper sur- 
face of absorption of certain remedies have been clearly 
made out. I will only mention the following : — 

i See "Medical Times and Gazette," for Feb. and June, 1859, pp. 156, 647. 
2 See "Journal de la Physiologie de l'Homme," &c., 1860, voltiii. p. 443. 

9 



74 DIAGNOSIS AND TREATMENT OF 

1. Professor Bernard * and other observers have ascer- 
tained that woorara is hardly absorbed by the mucous 
membranes of the mouth and stomach, while it is very 
quickly absorbed when put in contact with some other 
membranes, or with the subcutaneous cellular tissue. 

2. Mr. W. S. Savory 2 has ascertained that strychnine 
is absorbed so much quicker by the mucous membrane 
of the rectum than by the stomach, that a dose only 
one-fourth of another will act with greater energy in 
the rectum than the much larger dose in the stomach. 

3. I have found that ointments of belladonna and 
opium employed against neuralgic and other uterine 
pains act with greater rapidity, and much more benefit, 
when pushed up on a small lint ball in the rectum than 
in the vagina ; showing that absorption is more rapid by 
the mucous membrane of the rectum than by that of 
the vagina. 3 

Not long ago, the method consisting in applications 
of narcotics on the skin, deprived of its epidermis by a 
blister, was rather thrown into the shade, owing to the 
superiority of the hypodermic method. I protest, 
however, against the abandonment of a method which 
has the double advantage of counter-irritation and rapid 



1 Lemons sur les Effets des Substances Toxiques et Mcdicamenteuses, Paris, 
1857, p. 283. 

a See " The Lancet " for 1863, vol. i. pp. 515, 548. 

3 According to Charpentier, jun., hyoscyamine, daturine, and atropine pro- 
duce their effects quicker after having been injected in the rectum than by the 
hypodermic method. I have made comparative experiments, which do not con- 
firm this statement. It seems true, however, that, in certain persons, absorption 
of atropine is almost as rapid by the mucous membrane of the rectum as by the 
cellular tissue, under the skin. (See the researches of Charpentier in "An- 
nuaire de Therapeutique de Bouchardat pour 1864," p. 21, et seq.) 



FUNCTIONAL NERVOUS AFFECTIONS. 75 

absorption of a narcotic, and which may sometimes 
prove more useful than subcutaneous injections. In a 
case of crural neuralgia which had not been markedly 
benefited by hypodermic injections of morphia and atro- 
pine, I have obtained a quick amelioration, and ulti- 
mately a cure, from a series of blisters (by the hartshorn 
ointment) and applications of sulphate of morphia on 
the denuded dermis. 1 

There are two other methods of administration of 
remedies which have lately been much employed, es- 
pecially, however, against affections quite different from 
neuroses. One of them, consisting in inhalation of 
pulverized fluids, may be very useful against asthma, 
spasm of the glottis, whooping-cough, paralysis of the 
pharynx or larynx, &c. The other method, which 
consists in smoking medicated cigars and cigarettes, may 
be employed with advantage, not only against the laryn- 
geal and other neuroses just named, but also against 
epileptic laryngismus, hysteria, and even tetanus. Hyo- 
scyamus, stramonium, belladonna, and many other rem- 
edies, can be used by one or the other of these two 
methods of administration. 

IV. SELECTION OF REMEDIES. 

The time is fast coming when many complex reme- 
dies will be but seldom employed, and their active 

1 I do not speak of a mode of administration of narcotics proposed by M. 
Lafargue ("Bulletin de Therapeutique," Jan. 15, 1861, p. 22), as I do not see any 
advantage in it over the hypodermic method. It consists in the introduction, 
under the skin, of small, hard cylinders composed of mucilage, with a little pow- 
dered sugar and the usual dose of atropine, morphine, strychnine, veratrine, &c. 



76 DIAGNOSIS AND TREATMENT OF 

principles almost exclusively used. Belladonna, the 
preparations of which are so extremely variable in 
strength, and on which, therefore, we can place but lit- 
tle reliance, will be one of the first of the complex reme- 
dies almost altogether abandoned, to be replaced by its 
active principle which possesses its essential physiological 
and therapeutic properties. 

But some complex remedies, such as opium, and par- 
ticularly its tincture, will escape the fate of belladonna 
and other substances, owing to the fact that its effects 
cannot be fully obtained by the use of any of the large 
number of very different active principles it contains. 
Besides, in some remedies which seem to contain but one 
active remedial principle, there are physiological and 
therapeutical properties which appear not to exist in the 
only yet known active principles extracted from them. 
This is said to be the case with cantharidine, which 
does not seem to have the power of the tincture of can- 
tharides on the genital organs. 

Amongst the active principles which have recently 
been used instead of the complex substances from which 
they are extracted, the principal are atropine, veratrine, 
the valerianic acid, digitaline, and even aconitine, not- 
withstanding the real worth of Fleming's tincture of 
aconite, and notwithstanding also the assertion (which 
my experience contradicts) of Schroff, that aconitine acts 
differently from aconite. 



FUNCTIONAL NERVOUS AFFECTIONS. 77 



V. ANTAGONISM BETWEEN SEVERAL IMPORTANT REMEDIES. 

It would be out of place, in such a course of lectures 
as this, to enter into full details on this important sub- 
ject. I cannot, however, avoid saying a few words, at 
least, on the antagonistic effects of remedies which are 
very frequently employed together in cases of functional 
nervous affections. I will first speak of the antagonism 
between the properties of opium and those of bella- 
donna, stramonium, alcohol, and quinine. The an- 
tagonism of belladonna and opium has been known for 
centuries. Recently, however, more accurate notions 
have been obtained on this subject, owing particularly 
to the researches of Professor Behier, 1 Dr. C. C. Lee, 2 
Dr. W. F. Norris, 3 and Drs. S. W. Mitchell, Morehouse, 
and Keen. 4 From the researches of these practitioners 
and experimenters, as well as from my own, it results, 
that, besides the well-known antagonistic effects of these 
two remedies on the eye, there is a decided antagonism 
between them as regards their effects on the heart, on 
the brain, and on the spinal cord. In consequence of 
this antagonism, the dose of opium to produce sleep 
ought to be greater than usual, if belladonna is employed 
w T ith it ; and also the dose of belladonna against reflex 
paraplegia ought to be greater than usual, if the patient 



1 See "Bulletin de Therapeutique pour 1859," vol. lvii. p. 41. 

2 See " The American Journal of the Medical Sciences " for January, 1862, 
p. 54. 

3 See the above-quoted Journal for October, 1862, p. 395. 

4 See " The American Journal of the Medical Sciences," for July, 1865, p. 67. 



78 DIAGNOSIS AND TREATMENT OF 

is also taking opium. I might say the same thing as 
regards the antagonism between opium and stramonium 
or hyoscyamus. 1 We owe to Dr. Gubler 2 the discovery, 
that in many respects, and particularly as regards its 
action on the brain, quinine is antagonistic to opium; 
and that, consequently, it may be wrong or right, ac- 
cording to circumstances, to employ these two remedies 
together. Many facts tend to show also, that alcohol is 
able to neutralize some of the properties of opium, and 
particularly its influence on the heart and the skin. Of 
other remedies often employed in neuroses, one of the 
most important — strychnine — is somewhat neutralized 
in its effects by aconite, camphor, woorara, and the cala- 
bar bean. There is also an evident antagonism between 
strychnine and belladonna and the ergot of rye, as I 
have shown elsewhere. 3 

The kind of antagonism I have spoken of cannot be 
considered as due to a chemical neutralization. As re- 
gards this last kind of antagonism, it is important to 
know, that the most powerful Remedies we can employ 
against neuroses may be rendered inert by the chemical 



1 Notwithstanding the number of cases of apparent cures of poisoning by- 
opium, under treatment by belladonna, I persist, as does also Bouchardat 
("Ann. de Therap. pour 1860," p. 24) in recommending, that poisoning by opium 
be fought against by coffee, by keeping the patient awake by active and passive 
movements, and by making him walk, if this is possible. The experiments of 
Onsum (" Schmidt's Jahrbiicher der Gesammten Medecin," 1865, vol. 128, p. 288), 
of Camus ("Gaz. Hebd. de Med.," 1865, p. 498), and my own, show, that death by 
opium takes place from the same dose, whether we employ belladonna or not. 
These experiments clearly establish, that the toxic effects of these poisons, in 
certain animals at least, do not neutralize each other. 

2 Gazette des Hopitaux, 1858, p. 62. 

3 See " Lectures on the Various Forms of Paralysis of the Lower Limbs," 
Philadelphia, 1861. 



FUNCTIONAL NERVOUS AFFECTIONS. 79 

influence of certain substances which might be employed 
with these remedies. We are indebted to Dr. A. Gar- 
rod for the demonstration, that alkalies, and particularly 
the liquor potassse, destroy the active principles of bella- 
donna, stramonium, and henbane. 1 Bouchardat has 
shown, that almost all, and perhaps all, the known 
alkaloids, are precipitated by the iodide of potassium 
combined with iodine. 



VI. ON DOSES OF REMEDIES. 

A few remarks deserve to be made under this head. 
The first one is, that small doses of most remedies are 
useless, and therefore allow nervous affections to take 
deeper root in the system ; so that we ought (particu- 
larly in epilepsy, in tetanus, in neuralgia, in reflex para- 
lysis, in angina pectoris, in whooping cough, &c.) to 
give as large doses as can safely be borne. The second 
remark is, that before employing large doses, especially 
of opium, we must carefully ascertain, that the principal 
glands, and particularly the kidneys, are all right; as, if 
not so, a large but ordinarily safe dose might be found 
toxic. And another remark is, that in affections like 
tetanus, in which there is an antagonism between the 
complaint and the remedy, at the same time that we 
must be giving every hour, or every half-hour, a fresh 
dose of the remedy, we must be carefully watching for 
the disappearance of the symptoms of the nervous affec- 

i See " The Lancet," Loudon, 1857, vol. ii. p. 577. 



80 DIAGNOSIS AND TREATMENT OF 

tion, and their replacement by the symptoms of poisoning 
by the remedy. In an unpublished case, of which I 
happen to know the details, an able physician, Dr. P. 

G succeeded in obtaining the cessation of tetanic 

symptoms ; but, unfortunately, new doses of opium were 
given after that cessation, and the patient died of poison, 
ing by opium. 

VII. ASSOCIATION OF REMEDIES. 

In the treatment of functional nervous affections, most 
physicians often give simultaneously to the same patient 
two or more powerful remedies. This plan, which I 
almost always follow in treating certain neuroses, has 
very great advantages ; but it is not free from the danger 
of doing harm to the patient or, at least, of preventing 
the good effect of one remedy by some influence of 
another. Clinical observation proves the danger and the 
advantages of that plan, in demonstrating that the three 
following changes may take place when two powerful 
remedial agents are employed together : first, the cura- 
tive properties of one or both of these substances may be 
diminished or destroyed by the influence of one upon 
the other ; secondly, the properties may be increased ; 
thirdly, new properties (useful or injurious) may re- 
sult from the influence of one remedy upon another. 
Our ignorance as regards the action of remedial sub- 
stances, one upon the other, in presence of the tissues and 
fluids of the human organism, is too great for our trying 
blindly to employ large doses of powerful remedies 



FUNCTIONAL NERVOUS AFFECTIONS. 81 

simply on the ground of our knowledge of the action of 
these remedies when given alone, and still less on the 
ground of our knowledge of their chemical influences, 
one upon the other, before they enter the human organ- 
ism. Experiments, therefore, on the therapeutic effects 
of two, or more, powerful remedies employed together, 
should be made first w T ith small doses, to be gradually 
increased if the effects show that this can be safely 
done. 

The importance of the association of certain reme- 
dies against neuroses has attracted my attention for a 
great many years, but especially since March, 1860, 
after my appointment to the post of physician to the 
National Hospital for the Paralyzed and Epileptics, in 
London. By the end of that year, my colleague, Dr. 
Ramskill, and myself began treating epilepsy with large 
doses of the bromide of potassium. I was soon led to 
associate the iodide of potassium with the bromide ; and it 
became almost at once evident, that, in most cases of epi- 
lepsy (whether idiopathic, symptomatic, or sympathetic, 
but especially in that form, which is much more common 
than it is admitted to be, in which that convulsive affec- 
tion is allied w T ith, or due to, a congestion of the base of 
the brain or its meninges), these two remedies did more 
good than either of them alone. By the end of 1861, 
after I had ascertained that the bromide of ammonium 
has a special therapeutic influence in cases of congestion 
of the medulla oblongata and of the upper parts of the 
spinal cord, I began to associate that salt with the bromide 

and the iodide of potassium in the treatment of epilepsy. 

10 



82 DIAGNOSIS AND TREATMENT OF 

In 1862 and 1863, some of my American patients hav- 
ing been either corsiderably relieved or apparently cured 
by the combined use of these salts, my prescriptions 
were spread broadcast over the United States, by the 
patients themselves, by their friends, and by greedy or 
quackish chemists. That mode of treatment of epilepsy 
has, in this way, been submitted to an extensive trial, 
which leaves no doubt as regards its superiority. Al- 
though it certainly does not often cure permanently, it 
usually diminishes considerably the violence and the fre- 
quency of attacks, and is much more successful than the 
various modes of treatment by the best remedies against 
epilepsy, such as atropine or belladonna, the sulphate of 
copper, the nitrate of silver, strychnine, valerian, zinc, 
digitalis, or the means of counter-irritation by applica- 
tions of ice, moxas, croton oil, &c, on the spine or the 
head. 

In cases in which patients had derived no benefit, or 
had ceased to have any, from the use of one of the 
above remedies, or of the bromide or iodide of potassium, 
alone or combined, or of the bromide of ammonium 
alone, I have very often ascertained the superiority of 
curative influence of the association of the bromide of 
ammonium with the iodide and bromide of potassium. 
A decided and lasting amelioration was obtained in most 
of those cases from the use of the three salts together. 

My usual prescription for an adult, in cases of idio- 
pathic epilepsy, and also in cases of that convulsive af- 
fection apparently caused by a congestion of the base of 
the brain or of its meninges, is the following : — 



FUNCTIONAL NERVOUS AFFECTIONS. 83 

K. Potassii Iodidi, 5 j. 
Potassii Bromidi, § j. 
Amroonii Bromidi, 5 ij. ss. 
Potassa? Bicarbonatis, E) ij. 1 
Infus. Caluinbae, fL, § vj. 
M. 
A teaspoonful before each of the three meals, and three teaspoon- 
fuls at bedtime, with a little water. 

In cases of syphilitic epilepsy, I hardly need to say 
that the prescription must be modified so as to contain a 
good deal more of the iodide of potassium (five or six 
drachms instead of one). In cases of epilepsy in which 
the attacks are ushered in by a violent laryngismus or 
trachelismus, I change the relative quantity of the two 
bromides, diminishing by two drachms the bromide of 
potassium, and increasing by one drachm, or one and a 
half, the bromide of ammonium. 

There are rules relative to the treatment of epilepsy 
by the bromides of potassium and ammonium, employed 
together or separately, which are of so great importance, 
that I will take this opportunity to mention them briefly, 
postponing the details till I treat especially of epilepsy. 
These rules are, — 

1. That the occurrence during the day of the sleepi- 
ness caused by these remedies can be avoided by giving 
relatively small doses in the daytime, and a much 
larger dose late in the evening. 

2. That the quantity of these medicines to be taken 

1 When the patient's pulse is weak, I substitute for the bicarbonate of potash 
the sesquicarbonate of ammonia, and for the six ounces of infusion of Colombo, an 
ounce and a half of the tincture of that medicine with four ounces and a half of 
distilled water. 



84 DIAGNOSIS AND TREATMENT OF 

each day must be large enough to produce an evident 
though not complete anaesthesia of the fauces and upper 
parts of the pharynx and larynx ; that daily quantity 
being (according to the idiosyncrasy of the patient) from 
forty- five to eighty grains of the bromide of potassium, 
and from twenty-eight to forty-five grains of the bromide 
of ammonium, when only one of these salts is employed, 
and a smaller quantity of each, but especially of the 
second, when they are given together. 

3. That, considering that the bromide of potassium 
(and, in a small degree, also the bromide of ammonium) 
very rarely produces any good effect against epilepsy, 
without producing also an acne-like eruption on the 
face, neck, shoulders, &c, and that there seems even to be 
a positive relation between the intensity of the eruption 
and the efficacy of the remedy against epilepsy, — it is 
most important to increase the dose when there is no 
eruption, and also when the eruption is disappearing, 
unless the dose given in the twenty-four hours is already 
so large, that any increase of it produces great sleepiness 
in the daytime, a decided lack of will and of mental 
activity, dulness of the senses, drooping of the head, 
considerable weakness of body, and a somewhat totter- 
ing gait. 

4. That it is never safe for a patient taking either of 
the bromides or both, and receiving benefit therefrom, to 
be even only one day without his medicine, so long as 
he has not been at least fifteen or sixteen months quite 
free from attacks. Indeed, it is very frequent that pa- 
tients neglecting this rule are seized again with fits after 



FUNCTIONAL NERVOUS AFFECTIONS. 85 

an immunity of several or of many months, one, two, or 
only a few more days after the interruption of the treat- 
ment. In several cases, even after an apparent cure of 
ten, eleven, or twelve months, and, in one instance, of 
thirteen months and a few days, there has been a re- 
appearance of the disease after the treatment had been 
abandoned for only a few days, or a week. One of the 
ablest physicians of the United States, my friend Dr. 
Edward H. Clarke, has made a similar observation in one 
case after an interruption of the fits for a whole year. 1 

5. That the debilitating effect of the bromides in pa- 
tients already weak, as are most epileptics, ought to be 
prevented or lessened by the use of strychnine, arsenic, 
the oxide of silver, ammonia, or cod-liver, cold douches 
or shower-baths, and, of course, wine and a most nour- 
ishing diet. 2 

6. That iron and quinine — which are generally in- 
jurious to epileptics, except in cases in which their ner- 



1 It has recently been stated by Dr. Namias, of Venice, and by Dr. Rabuteau 
("Gazette Hedornadaire de Medecine, etc., 24 Avril, 1868," p. 263), that the 
bromide of potassium is still found in the urine a very long time after it has 
been taken. Namias says he found it after fourteen days, and Rabuteau after a 
month ; but they do not say how much they found, and their experiments were 
made on small animals. My friend, Dr. Hameau, grounding his opinion on the 
researches of Namias, thought that the bromide of potassium accumulates in the 
system, and explained in that way the death of a patient poisoned by that salt 
("Journal de Medecine de Bordeaux, Mars, 1868"). I will only remark here 
that the patient took at times sixteen grammes (more than half an ounce) a day 
of that powerful remedy. 

2 In making use of strychnine or arsenic, it must be kept in mind that not 
only the bad influence of the bromides, but also their favorable influence against 
epilepsy can be diminished by these powerful agents (especially strychnine), and 
that it is, therefore, necessary when these agents are used to increase the dose of 
the bromides. The antagonism between strychnine, which acts in increasing the 
reflex faculty of the nervous centres, and the bromides, which diminish that 
faculty, may be so great as to produce almost a complete annihilation of the influ- 



86 DIAGNOSIS AND TREATMENT OF 

vous affection is caused, or at least aggravated, by chlorosis, 
ancemia or malarial cachexia — are more particularly 
injurious in cases in which the bromides are taken. 1 

7. That a gentle purge every five or six weeks usually 
gives a new impulse to the usefulness of the bromides 
against epilepsy. 

The association of the bromides of potassium and of 
ammonium with the iodide of potassium has also given 
me better results than the use of one only or two of these 
remedies in the treatment of chorea, of hysteria, 2 of re- 
flected and other kinds of spasms or contracture, of re- 
flected neuralgia, of several forms of mental disorder due 
to a peripheric irritation or to an intra-cranial conges- 
tion, &c. 

I have observed a very curious fact in employing 
together the bromide of potassium and the bromide of 
ammonium. I have ascertained, that, without produ- 
cing the phenomena which constitute what has been 
called bromism (anaesthesia of the throat, nostrils, &c., 
weakness especially of the neck and spine, lack of will, 
sleepiness, stupidity, &c), I could give in a day sixty 

ence of the bromides, and partly that of strychnine. In one case, 132 grains a 
day of the bromides were taken without the least appearance of bromism and 
without any controlling effect over epilepsy, when the patient was taking about 
one-third of a grain of strychnine a day; while he was strongly bromidized under 
the influence of 80 grains a day of the bromides, when he was not taking strych- 
nine. 

1 There is, however, a salt of iron, which, when given in moderate doses, 
seems frequently to act favorably, and without any hindrance, in epileptics : it is 
a double salt, the citrate of iron and strychnine. 

2 The above compound remedy, however useful, is not one of the best means 
of treatment against hysteria. Opium and sulphuric ether (internally), in large 
doses, are certainly much superior to that compound against the various forms of 
hysteria. So also that compound has not as much power as arsenic or strych- 
nine against chorea. 



FUNCTIONAL NERVOUS AFFECTIONS. 87 

grains of the bromide of potassium and thirty grains of 
the bromide of ammonium, while, if I replaced the thirty 
grains of this last salt by only twenty grains of the other 
salt so as to give eighty of the bromide of potassium 
alone, bromism was usually produced. And also, if, in 
place of the sixty grains of bromide of potassium, I added 
to the thirty grains of bromide of ammonium from 
twenty to twenty -five grains of this same last salt, brom- 
ism was again produced. So that ninety grains, i.e. a 
larger dose, of the two remedies taken together did not 
produce bromism, while a smaller dose of either em- 
ployed alone did produce it. If we call bromism a bad 
effect, and if we call a good effect the favorable influ- 
ence of these remedies in epilepsy and other neuroses, 
it can be said that their association in certain doses 
diminishes their bad effect, while it increases their good 
effect. 

The association of several other remedies leads to 
nearly similar conclusions as regards then action. For 
instance, I have found that the association of belladonna 
to stramonium, to hyoscyamus, to conium, or to aconite 
(substances which seem, when taken alone, to produce 
many similar phenomena), increases their good effect, 
and certainly does not increase, and even seems to 
diminish, some of their bad effects. 

I have obtained much greater benefit against neuralgia 
or other pains from a combination of the following ex- 
tracts, than from either of them alone, or from the asso- 
ciation of only two or three : — 



88 DIAGNOSIS AND TREATMENT OP 

R. Extracti Belladonnas, gr. -I . 
Stramonii, gr. -}. 
Cannab. Indicag, gr. -\. 
Aconiti, gr. J. 
Opii, gr. i. 
Hyoscyami, gr. f . 
Conii, gr. j. 
Glycyrrhizae pulvis, 9, s. 
For one pill. 

According to circumstances, I have given, without pro- 
ducing any great disturbance, three, four, and even five of 
such pills in a day, and, sometimes, in about eight or 
ten hours. It is evident, that it would not have been so, 
had the toxic effects of each of these extracts been added 
to those of the others. There must be, therefore, some 
influence exerted by some of these substances upon the 
others diminishing their bad, and not their good, effects. 

The association of remedies which are known to be 
more or less antagonistic to each other, as regards their 
bad effects in large doses when employed alone, has been 
very little studied. Great advantages may be obtained 
by such associations, if the favorable effects of the asso- 
ciated remedies remain entire or nearly so, and still 
more if, as seems to be the case for the bromides of 
potassium and of ammonium, these effects are then in- 
creased. Only a few physicians seem to have paid atten- 
tion to the question of association of remedies. Mialhe, 
in his ingenious work on the action of remedies, 1 has 
studied the question in its chemical aspect, which is but 
a very small part of it. I know but very few original 

1 Cliinrie appliquee & la Physiol, et a la Therapeut. 1856, p. 554. 



FUNCTIONAL NERVOUS AFFECTIONS. 89 

papers on this subject, in which its importance is duly 
appreciated. Two of them are well worthy of mention : 
one is by Dr. Eisenmann, of Wiirzburg, 1 and treats of 
the influence of association of opium with many other 
remedies ; and the other, by Dr. Nivison, of Hector, 
N.Y., 2 on the association of opium, also, with quinine. In 
the treatment of neuroses, researches on this subject 
would well repay those who would undertake them. 

1 Bulletin general de Therapeutique, vol. lvii. Juillet, 1859, pp. 26 et 81. 

2 American Journal of the Medical Sciences, July, 1861, p. 51. 



11 



ERRATUM. 

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doses when employed alone," read "bad effects when employed in large 
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